
Copyright }j°_ 



COPYRIGHT DEPOSIT. 



"In the schools of Hellas at least one aspect of school hy- 
giene, namely, physical education, was recognized as a means 
of developing the ideal citizen — the true function of educa- 
tion." — Hogarth. 

"A national school which trained the minds only and neg- 
lected the bodies of the pupils would have been inconceivable 
to a Hellene." — Freeman. 



THE HEALTH INDEX 
OF CHILDREN 



BY 

ERNEST BRYANT HOAG, M. A., M. D. 

MEDICAL DIRECTOR OP BERKELEY SCHOOLS, LECTURER 
IN PUBLIC HYGIENE IN THE UNIVERSITY OP CAL- 
IPORNIA, AUTHOR OP "HEALTH STUDIES." 
MEMBER OP THE ROYAL SANI- 
TARY INSTITUTE, LONDON 



WITH PRBPATORY NOTE BY 

FRANK F. BUNKER, Ph. B. 

SUPERINTENDENT OP BERKELEY SCHOOLS 



SAN' FRANCISCO 

WHITAKER & RAY-WIGGIN CO. 

1910 



v3 



^^o^ 



Copyright, 1910 
WHITAKER & RAY-WIGGIN CO. 



C CIA'^78688 



TO MY BROTHER 

JUNIUS CLARKSON HO AG, M. D. 

TO WHOSE SKILLFUL, MINISTRATIONS, MANY CHILDREN 
OWE THEIR HEALTH AND HAPPINESS 



PREFATORY NOTE. 



More than two thousand years ago, Plato said that "Med- 
icine is the science of health," and one of the most common- 
place of our proverbs tells us that "Prevention is better than 
cure," yet today it is only with the greatest possible difficulty 
that the public can be convinced that the prevention of de- 
fects in school children is better than their cure. It will not be 
long however, before every school, which makes any claim to 
progressiveness, is provided with intelligent supervision of 
the health conditions of its pupils. In the larger places this 
work will be placed in charge of experts who have been 
practically trained. Many places, however, are too small to 
justify the expense of securing experts. In such situations 
the teacher must be relied upon for services of this character. 
Indeed even in the larger cities where a corps of trained ex- 
perts have the work in hand much must be demanded of the 
teacher if the work be successful. It is therefore important 
that every teacher familiarize herself with the fundamental 
things which are now known about the health conditions of 
the child. 

An intelligent teacher or parent even though he may not 
have had technical training, can easily learn to observe the 
ordinary signs and symptoms which indicate physical defects, 
for these relate to such points as posture, appearance of teeth, 
mental activity, colds, deafness, offensive breath, mouth 
breathing, inattention at home or in the school room, and 
delinquency in studies. The significance of these symptoms 
is obvious to the thoughtful individual even though he may 
never have had the advantage of special preparation. 

The purpose of Dr. Hoag in this book is to give to teachers 
and parents a series of suggestions drawn from his own 



Prefatory Note 

broad and rich experience, which if carefully apprehended, 
will lead to intelligent action. Many persons interested in 
this movement have searched without success for a simple 
work of this character written in untechnical language. I 
believe the writer has been happy in making clear and help- 
ful that which most observers have found confusing. 

FRANK F. BUNKER, 

Superintendent of Schools, 

Berkeley, California. 



INTRODUCTION. 



The Health Index of Children. 

A few years ago a child was considered in health so- 
long as he did not show the familiar signs of disease. 
Even doctors often failed to read the plain language 
of many physical defects because they had not been 
trained to do so. In most places it is still not custom- 
ary to regard a child as unhealthy because his upper 
teeth are prominent, uncovered by his lip, and perhaps 
crooked. Yet every teacher, parent, and physician 
ought to know that such a picture presents almost 
sure signs of adenoids, and that no child with adenoids 
can be truly healthy. Few school communities even 
now regard decayed teeth in a child as indicative of 
poor health, yet it is an incontrovertible fact estab- 
lished by the highest authorities that no child or even 
adult with seriously defective teeth can possibly pos- 
sess good health. 

We have always been accustomed to certain bad 
conditions which because of their frequency of occur- 
rence have never been regarded seriously. Many such 
conditions in children have, therefore, always existed 
without exciting comment. They have usually been 
accepted as incidents of childhood, and their possess- 
ors as types, deserving no special attention. Now a 



Introduction 

cross-eyed child is not a necessary type, nor is an ear- 
ache a natural incident in any child's life. Both are 
positive signs of underlying serious causes, and are in 
themselves only secondary results which might usually 
have been rather easily avoided. ]\Iany signs of physi- 
cal troubles among children may be read by anj^one 
who will take the trouble to learn the language. To 
this sort of observation Mr. W. H. Allen has given 
the title, "Reading the Health Indexi." 

The most valuable asset that any child can possess is 
good health. This consideration of health as essen- 
tially valuable in life, is largely a new conception, and 
is characteristic of the trend of thought of the Twen- 
tieth Century. AYithout good health no individual can 
possibly live up to his highest ideals physically, mor- 
ally', intellectually, or even commercially. He is handi- 
capped in life's race. The health of the child very 
largely determines the success of the adult, and what 
we should be most concerned about in education is the 
laying up of vital assets for use in the active battle of 
life. 

Individual and national vitality are the dominant 
notes today. "Poor seed yields poor fruitage." In 
the past this obvious fact has been largely ignored as 
far as it applies to the health of children, but today 
the most progressive schools in every country are ser- 
iously attem])ting to imi)rove the seed from which 
nations grow, for good citizenship mostly depends up- 
on the vitality of the seeds from which citizens s])ring. 
For this reason the development of a sound body is 

'Civics and Healtli (Allen). 



Introduction 

rapidly becoming the most important function of the 
School in the education of the child. You cannot 
properly educate a child who has not good health, so 
one writer has said, and another prominent school man 
has gone so far as to say that in the light of recent 
information relating to the health of school children, 
a community which neglects the systematic care of its 
school population is guilty of criminal negligence. 

We must so educate children that they will possess 
good health and keep it in after life. ''Education's 
highest aim is to train us to do the right thing at the 
right moment without having to think." The right 
thing in health will be done only when we are so edu- 
cated that we do not have to think about it. 

This book is an outgrowth of a series of lectures 
given to teachers in the Schools of Berkeley and Pasa- 
dena, to mother's clubs in the same cities, and to my 
classes in School Hygiene in the University of Califor- 
nia. The material has, therefore, been pretty well 
tried out, before being placed in book form. 

The object of this little manual is to show teachers 
and parents how to detect easily those ordinary physi- 
cal defects of the child which bar his progress in school 
and life, and to suggest means by which such defects 
may be removed and good health afterwards main- 
tained. Incidentally it may prove of some value to 
physicians who are for the first time applying them- 
selves to this special sort of Public Health work. 

While most of the material presented here has been 
drawn from my own rather extended experiences as 
Medical Officer in schools, I have made full use of 



Introduction 

many well known works on Child Hygiene and related 
subjects. Reference is made to these in foot notes 
throughout the book. 

To Professor Alexis F. Lange, of the department of 
education of the University of California, I am indebt- 
ed for reading and criticising the proof sheets from 
the point of view of the University student's need: to 
Professor Kemp, of the Han Diego Normal School 
for similar service from the standpoint of the Nor- 
mal student's requirements. Several Superintendents, 
teachers and Medical Inspectors of California public 
schools have furnished valuable suggestions, for which 
I am si)ecially grateful. The publishers of the author's 
''Health Studies," (I). C. Heath & Co.) have court- 
eously given me permission to use certain extracts from 
that book. 



Berkeley, California, October 1, 1910. 



CONTENTS 



PART I. THE HEALTH INDEX 

Diagnostic Table 13 

I. The Nose, Throat and Ear 17 

II. Defects of Vision • . .31 

III. Defective Teeth 39 

IV. Contagious Diseases and Scliool Sanitation . . 47 

V. Nervous Disorders of Children .... 75 

VI. Some General Disorders of School Children . 92 
VII. Defects of the Feet . . . . . .98- 

VIII. Posture .105 

PART II. THE CHILD AND HIS ENVIRONMENT 

IX. Foods for Children 115 

X. Health at Home in Relation to School Health . 128 
XL The Health of the Teacher 136 



PART III. HEALTH ORGANIZATION IN SCHOOLS. 

XII. An Office System for School Health Departments 153 

XIII. A General Plan for Health Supervision in Schools 165 

XIV. Some Details of the Physician's Examinations . 177 

XV. The Co-operation of School Health Departments 

With Other Agencies 181 

Bibliography 186 



PART I 

THE HEALTH INDEX 



Diagnostic Table 



DIAGNOSTIC TABLE 



Signs of Disorders and their Indications. 

(To be observed by teacher or parent.) 



SYMPTOMS. 
Mouth breathing 
Prominent upper teeth 
Loud breathing 
Nasal voice 
Catarrh 
Running nose 
Frequent colds 
Sore throat 
Offensive breath 
Cough 

Blank expression 
Slow mentality 
Deafness 

Poor physical development 
Earache 
Discharge 
Inattention 
Poor spelling 
Watching of lips 
Slow progress 
Headache 



INDICATIONS. 



Disorders of Nose, 

Throat and Ear. 

(Chapter I.) 



Sore eyes of any kind 

Styes 

Congested eyes 

Crossed eye 

Squinting 

Headache 

Peculiar postures when reading 

Holding book too near face 

Poor reading or spelling 

Dizziness 



Bye Disorders and 
y Defects. 
' (Chapter II.) 



14 



DiAGNOsi'ic Table 



Decay of teeth 
Discoloration 
Crooked teeth 
Prominent teeth 
Offensive breath 
Poor articulation 
Broken teeth 
Mal-nutrition 



Teeth Defects. 
(Chapter III.) 



Pallor 

Flushed face 

Eruptions 

Scratching 

Sleepiness 

Lassitude 

Vomiting 

Headache 

Cough 

Running nose 

Congested eyes 



Contagious Diseases 
>- (Chapter IV.) 



Inability to hold objects well 

Spasmodic movements 

Twitching of eyes, face or any part 

of the body 
Irritability 
Fits 

Bad temper 
Fainting 
-Nail biting 

Undue emotion of any sort 
Frequent requests to "go out" 
Timidity 
Stammering 
Cruelty 

Perverted tastes 
Moroseness 
Solitary habits 
Undue embarrassment 
Undue activity 
Misbehavior 
Sex perversions 



Nervous Disorders. 
(Chapter V.) 



Diagnostic Table 



15 



Pallor 

Emaciation 

Enlarged glands in neck 

Puffiness of face or eyes 

Shortness of breath 

Lassitude 

Perverted tastes (e. g. foods) 

Slow mentality 

Peculiar or faulty postures 

Under development 

Excessive fat 

Vicious personal habits 

Low endurance power 

Irritability 

Disinclination to play 

Fatigue. 

Walking "pigeon toed" 

A shuffling, inelastic walk 

Toeing markedly out 

Advancing foot by exaggerated knee 

action 
Long axes of foot and leg meet at 

unusually wide angles 
Shifting from foot to foot 
Standing on outer edge of feet 
Locking knees 
Leaning against wall or desk 
Shoes run over at either side 
Front of heel worn down 
Outer and back part of heel worn 

down 
Wearing out of soles ^.syxaetrieally 
Congestion of the feet 
Swelling, puffiness 
Excessive perspiration 
Callouses 
Twitching of the foot muscles 



Nutritional and Gen- 
> 'eral Disturbances. 
(Chapter VL) 



>*Defects of the Feet 
(Chapter VII.) 



Incorrect Posture. 
(Chapter VIII.) 



Unequal height of shoulders 

Standing on sides of feet 

Prominent abdomen 

Flat chest 

Curved back 

Stooping 

*The teacher should remember always that painful "weak 
feet" are not necessarily flat and conversely that flat pronated 
feet may not be painful. 

No child will present all of the above symptoms. 



CHAPTER I 



THE NOSE, THROAT AND EAR. 

Among the common defects of children those of the 
nose, throat, and ear probably hold first place and of 
these, adenoids are perhaps of the greatest interest 
to a teacher or parent. It is quite impossible to state 
just what number of school children suffer from ade- 
noids, but it is safe to estimate the proportion at one 
in every seven or eight children between the ages of 
five and fifteen. 

Adenoids consist of soft vascular tissue forming a 
third tonsil. It is normal enough until it becomes 
overgrown. This tissue is found behind the soft palate 
between the nose and throat. It may completely close 
this passage and in many cases it becomes so closed 
when the child takes cold. For this reason an adenoid 
child breathes part or all of the time with the mouth 
open. This condition is what is known by the term 
"mouth-l)reathing." Mouth-breathing is not a bad 
habit that the child has acquired, but indicates that he 
cannot secure air in the normal manner through the 
nose, and must get it by breathing through his mouth. 
The child does much the same sort of thing that we do 
when we find the air too close in a badly ventilated 



18 



The Health Index of Chh.dkex 



room, we open the window. The child opens the only 
window he possesses which is his mouth, and thus ob- 
tains the necessary supply of oxygen. But even 
under the best of circumstances such a child labors 
under breathing disadvantages and probably never 
gets as much oxygen as his body needs. 

When one considers that many adenoid children 
spend much of their time in illy ventilated school 
rooms and sleep in bed-rooms with tightly closed 
windows, it is apparent that they labor under a con- 
stant and serious handicap.^ 




A Sectiou Through the Nose aud Throat Showing- Location 
of Ailenoirts (Fig. 1.) 

Adenoids may occur in infants a few months old 
but are more likely to be first noticed between the 

'Of 500 children questioned In the Berkeley schools, it was 
found that 2'i% of them habitually sleep in totally unventllated 
bed-rooms. 



The Nose^ Throat and Ear 19 

ages of three to five years. After puberty (12 to 16 
years) thej tend to disappear and are seldom found 
in adults. Because of this well known fact many 
parents, and unfortunately some physicians, prefer to 
allow nature to remove the obstruction by her own 
methods. The child will "out-grow" this, that, and 
the other difficulty, is a very common expression among 
such individuals. As a matter of fact there are rel- 
atively few physical difficulties which children unaided 
ever "outgrow" successfully. Adenoids, it is quite 
true, tend to disappear or be absorbed spontaneously, 
but they leave in their wake a most unfortunate train 
of results. Usually the teacher and most parents first 
detect adenoids by means of these unfortunate results. 
When the symptoms are so pronounced that they are 
apparent to the rather inexperienced observer, much 
harm has already been done. 

Reading the Index of Adenoids. 

Let any teacher look over her room of twenty or 
more pupils and she will nearly always discover sev- 
eral with some or all of the following signs or symp- 
toms of adenoids : 

1. A listless expression (the adenoid face.) 

2. A nasal voice. 

3. Open mouth (part or all of the time.) 

4. An under-developed chin. 

5. Prominent and often crooked upper teeth. 
G. A short upper lip (a relative matter.) 

7. A rather heavy expression in the eyes. 

8. A pronounced tendency to colds and catarrh. 



2U The Health Index of Chh.duen 

9. Slow mentality. 

10. A pale face. 

11. An under developed physique. 

12. A contracted chest. 

13. Ear ache. 

14. A running ear. 

15. Deafness. 

Of these signs and symptoms the most common and 
apparent are nasal voice, crooked and prominent teeth, 
earache, deaf)tess, and mouthhreathing. 

At home it will be noticed that the adenoid child 
sleeps Avith his mouth open, often snores, and some- 
times has "night terrors.'' If one looks into the mouth 
the palate will usually be found very high-arched in- 
stead of broad as in a normal individual. In the ma- 
jority of children, the tonsils Avill be found enlarged, 
and in many of them the lymphatic glands ("kernels") 
in the neck are swollen. 

It is apparent then that adenoids produce various 
deformities which no child will "out-grow" however 
completely the adenoid tissue itself may disappear. 
These deformities are chiefly the following: 

1. Prominent upper teeth. 

2. Crooked upper teeth. 

3. Receding or small chin. 

4. High arched palate.^ 

iThe high narrow palate pushes upon the nasal septum caus- 
ing it to become bent (deflected). This is a common cause of 
catarrh in the adult. 



The Nose^ Throat and Ear 21 

Children with adenoids usually possess less physi- 
cal resistance than other children. They fall easy 
victims to colds and various other contagious diseases, 
and have little physical endurance or mental vigor, 
They make slower progress in school and in general 
are much less buoyant and happy than the normal 
child.2 

Adenoids ought to be discovered before these unfor- 
tunate results have occurred. This is the duty of the 
parent and family physician. The first indications 
of inability to nurse well, mouth-breathing, (while 
awake or asleep), snoring, and a tendency to colds and 
catarrh must excite suspicion and the child should 
then receive a thorough examination by a competent 
physician. Let no parent trust the individual who 
tells him that his child will "out-grow" such condi- 
tions unless he has made a careful examination and 
has eliminated the possibility of adenoid obstruction. 

Diseased Tonsils. 

About one-eighth of school children appear to have 
seriously diseased tonsils. Most children who have 
adenoid tissue of sufficient importance to require re- 
moval, also have enlarged tonsils. This is easy to 
understand when we recollect that what we call "ade- 
noids" are made up of a third tonsil and consequently 
their structure is much the same. Enlarged (hyper- 
trophied) tonsils when they do occur without the pres- 
ence of adenoids are seldom easy to diagnose by meth- 

•It appears from our present investigations and especially 
those of Mr. Ijeonard P. Ayres that children with adenoids 
spend nine and one-tenth years in the eight elementary grades. 



22 The Health Index of Children 

ods of siipei'licial observation. However, a child who 
is subject to frequent attacks of sore throat, one who 
has offensive breath or a child with a thick voice, ought 
to be under suspicion of having enlarged or otherwise 
diseased tonsils. A history of qiiiiisij or tottsilitis 
nearly always indicates tonsils which are abnormal. 

It is rare that children who have normal tonsils are 
troubled with an}' form of sore throat. Acute sore 
throat always requires the most careful attention. No 
one can distinguish ordinary tonsi litis from diphtheria 
unless a culture is taken from the throat and a micro- 
scopical examination is made. A case of diphtheria 
which is not recognized early is a very serious matter 
and often results fatally. This is a fact that teachers 
and parents ought always to understand in consider- 
ing the tonsils. 

]Many tonsils have small holes or crypts in them 
which become filled with a white cheesy material. Such 
tonsils are diseased and retpiire careful attention. 

Sometimes tonsils are so greatly enlarged that they 
may be observed by merely asking the child to open 
his mouth. Remember that normal tonsils are barely 
risihJe, on each side of the root of the tongue. It ap- 
pears that pupils suffering from enlarged tonsils re- 
quire about seven-tenths of a year longer to complete 
their work in the grades than does the normal child. 

The Ears. 

Ear troubles of various sorts are very common 
among children and they often interfere seriously 
with progress in school. The commonest troubles 
with the ears are the following: 



Thk Nose^ Throat and Ear 23 

1. Earache. 

2. Ear Discharge. 

3. Deafness. 

Deafness may affect one ear only. It may affect 
both ears and yet be very slight. It may affect both 
ears serionsh'. In fact all degrees of deafness are 
discovered among school children when the hearing 
is carefully examined. 

When deafness is discovered it AVill usually be 
learned that the child has, or has had, adenoids, 
(see discussion of adenoids). There will usually be 
a history first of ear ache, followed sooner or later 
b}' discharge or what the child invariably calls running 
car. On the other hand, pain in the ears or discharge, 
or both, indicate that unless promptly treated deafness 
will inevitably occur in the great majority of 
cases. Pain, discharge, and deafness are not inci- 
dental conditions to be rather expected in childhood, 
as so many parents seem to suppose. They are in 
reality warning signals of conditions which unless 
heeded lead to serious and often permanent defects 
of hearing. 

"Pain in the ears is almost always an indication 
that an acute inflammatory process is developing. 
Ear-ache is of the greatest diagnostic value in all di- 
seases of the ear, and as a rule is the only (or at least 
earliest) symptom observed by parents, teachers, and 
physicians. * * * Ear-ache may be, and as a rule 
is, the onl.y symptom indicating the development of 
an acute disease of the middle-ear with all its pro- 
found and alarming complications, even of the mem- 
branes of the brain (brain-fever)." * 



24 The Health Index of Children 

In this same article by Dr. Zuill parents are most 
strongly advised against treating children with ear- 
ache drops. Such treatment only serves to give a 
false idea of security and never cures the conditions 
which are causing the pain. Pain of all sorts is Na- 
ture's warning signal that something is wrong. It is 
not a disease but a symptom of disease. It is never 
right to stop the pain without first attempting to 
discover its cause. Pain is like a bell-buoy on a danger- 
ous rock — it points to the place of trouble. One 
may easily stop the bell from ringing, but the danger- 
ous rock is still there. 

The Index of Ear Defects. 
Resides the symptoms named, pain, discharge, deaf- 
ness, there are other indications of ear troubles (one 
or several of which may present themselves,) which 
an intelligent teacher or parent ought to be able to 
detect. These include the following: 

1. Inattention. 

2. Headache. 

3. Poor Spelling. 

4. Expressionless Voice. 

5. Imperfect Articulation (because clear speech is 
not heard). 

0. Irritability. 

7. Stupidity of Countenance. 

Many children learn to spell by hearing rather than 
by sight, and consequently such pupils if deaf are 
considerably hampered in this respect. 

*Earache in Children, Los Angeles Medical Journal, January 
1905, Dr. W. L. Zuill, Pasadena. 



The Nose^ Throat and Ear 25 

One ought always to keep in mind tliat catarrh leads 
to deafness, and in itself indicates the necessity for an 
examination of the hearing A child with normal hear- 
ing should hear the tick of the average watch when 
placed in a line with the ear, about two feet away. 
In testing the ears the eyes should be shut and one ear 
closed with a finger of the same side. A loud whis- 
per with lips turned away from the listener should 
be heard about 25 feet away. To what extent de- 
fective hearing interferes with school progress is 
not at present possible to state exactly. That it does 
exert a definite unfavorable influence is, however, 
abundantly proven. 

The following rather ordinary cases of ear, nose and 
throat defects taken from a great many others among 
my experience, will illustrate what may be found in 
almost any school anywhere. 

1. A twelve year old girl showed signs of very poor 
general physical development. She was stunted in 
growth, had red eyelids, was slightly deaf, possessed a 
very slow mentality and suffered from constant colds. 

The usual physical examination at school showed 
enormous tonsils nearly meeting in the middle line of 
the throat. The nose was also obstructed with ad- 
enoids. As the parents could not afford to pay Tor 
medical treatment the child was sent by the school 
nurse to a competent specialist who volunteered treat- 
ment. Since her operation the child's eyes are nearly 
well, her hearing is acute, she seldom has colds, and her 
growth and general mental and physical condition 
have greatly improved. 



2G 



The Health Index of Children 





M 


^^^^^^r 


^^^H 




^ ^^1 

^^^H 







A Type of Child Often Seen in the Sehools 

(Adenoids.) 

2. A little girl of seven years suffered from constant 
ear-aclie and rnnning ear. For a long time the mother 
had washed out the ear Avith a strong solution of tea. 
She said that the child had had ear trouble since she 
was two years old and supposed she would always have 
it so saw no need of consulting a doctor. She Avas 
finally persuaded to bring the child to the clinic where 
proper treatment, including the removal of adenoids, 
practically cured the condition in five week's time. 

3. A boy fourteen years old had been deaf for nearly 
a year and ear ache was almost constantly present. He 



The Nose^ Throat and Ear 27 

had never been takeu to a doctor but the well-meauing 
though misguided mother had carefully poulticed, his 
ears each uight with Jiot hrcad. It Avas quite im- 
possible to make this mother understand the harm that 
this sort of treatment was doing. iVt last, as the boy's 
condition became much worse, the mother consented to 
have him sent to a ph^'Sician. An examination showed 
that both ear drums were ruptured and that there was 
chronic inflammation of the middle ear present. The 
boy received the best possible care and at present is at 
least free from pain. In this case permanent deafness 
might easily have been prevented by early detection of 
the trouble and prompt medical attention. As it is 
the boy's earning power in the world is greatly reduced 
and he will pass through life with a serious and quite 
unnecessary handicap. 

The common habit of putting good food in bad places 
would be funny if it were not often so serious a matter. 
Ears are washed with hot tea; sore throats (sometimes 
diphtheria) are wrapped in hacon; sore chests are cov- 
ered with stewed onions; boils are poulticed with 
hread and milk; and various other articles of food are 
wasted on the outside when they miglit do considerable 
good on the inside. 

4. A young girl of about sixteen jeava of age was 
employed in an Oakland Market where she worked 
daily on a wet asphalt floor. Repeated attacks of sore 
throat and rheumatism affecting many joints, brought 
her to a physician who at once discovered very large 
hui-ied tonsils, although an ordinary inspection of the 
throat showed little evidence of tonsilar disease. A 



2S Tiiic Health Index of Children 

heart murmur was also discovered, iDdicatiug a prob- 
able infection tlirough tlie tonsils. Immediate re- 
moval of the tonsils was advised to prevent further in- 
fection, with more serious heart complication. This 
advice was however ignored, and one month later the 
girl died of endocarditis, i. e. inflammation of the 
heart. This intlammation of the heart was, in this 
particular case, undoubtedly brought about by direct 
infection through the diseased tonsils, and prompt 
surgical attention would probably have prevented the 
disastrous result which followed neglect of treatment. 

The close relation which often exists between di- 
seased tonsils, tonsi litis, rheumatism and certain forms 
of heart disease is frequently observed by medical men. 

5. In looking over a 5th grade one day I observed a 
child of singularly listless apathetic appearance. She 
was pale and anaemic; she breathed with her mouth 
oj>en displaying a set of extremely crooked and decayed 
teeth. Her voice was nasal and her articulation most 
imperfect. Her progress in school had been slow and 
generally unsatisfactory. Upon closer investigation 
I found an extraordinarily high arched palate and tlie 
roof of the mouth so contracted that the forefinger 
could be barely passed in betAveen the up])er teeth of 
each side. The tonsils were large and adenoids ob- 
structed the nose. Notification to the parents of the 
condition present produced no result, nor did a home 
visit on the part of the nurse. One year later this girl 
now thirteen years of age, was sent to me again for ex- 
amination. The second teeth were now erupting in the 
most irregular manner possible, and the roots of the 



The Nose^ Tpiroat and Ear 29 

first teeth everywhere surrounded them. The deep 
narrow slit forming the roof of the mouth was filled 
with erupting second teeth, much delayed by the 
presence of the persistent but decayed first teeth. Mas- 
tication had become practically impossible because of 
')iial occlusion of the teeth, and the child showed every 
evidence of j)rofound nutritional disturbance. Her ig- 
norant parents still think that she is too young to have 
the condition attended to and that in a measure she 
will "out-grow" the trouble later. In the meanwhile 
Mary is very rapidly developing a deformed face and a 
jaw with teeth more like those of some fishes than a 
humau being's, for the inside of her mouth is now 
filled with misplaced teeth ! 

Resume on Nose, Throat, and Ear Troubles in Children.* 

An examination of school children shows that many of 
them suffer from nose, throat, and ear troubles. Probably at 
least 25% of our children in the schools of the United States 
have such defects. Why this is so we do not exactly know. 

Parents are very likely to be unfamiliar with these con- 
ditions. Often they do not know when their own children 
are afflicted in this way. 

No child can do his best work in school if he is suffering 
from some nose, throat, or ear trouble. The commonest 
conditions found in such children are enlarged, diseased 
tonsils, adenoids, earache, ear discharge, and deafness. 

The tonsils are glands in the throat, one on each side of 
the root of the tongue. When they are in a healthy con- 
dition they are barely visible. They often become much 
inflamed and sometimes there is pus present in them. They 
may obstruct breathing. 

Any child with diseased tonsils is likely to be sickly. 

*The following is published in pamphlet form for distribu- 
tion in the parent's clubs of the Berkeley schools. 



• >0 Tiiio Health Ixdiox of Ciiilhukx 

Any child with diseased tonsils is likely to have many at- 
tacks of sore throat, or tonsilitis. 

Diseased tonsils may result in Rheumatism and disease of 
the heart. 

Any child with diseased tonsils is very susceptible to con- 
tagious diseases. 

Any child with diseased tonsils has an increased tendency 
toward consumption. 

No child can be well or do his best work in school with 
diseased tonsils. 

Diseased tonsils should usually be removed and should 
always be treated. The operation is not dangerous. It 
always improves the child's health. 

Adenoids are soft spongy growths behind the soft palate, 
between the nose and throat. A child with adenoids usually 
breathes with his mouth open. He cannot breathe well 
through his nose. Mouth breathing is not a habit. 

Adenoids cause a child to sleep with his mouth open. 

Adenoids often cause a child to snore. 

Adenoids nearly always make the teeth come in crooked. 

Crooked and prominent teeth are nearly always caused by 
adenoids. 

Adenoids make a child take cold easily. 

Adenoids often give a child a stupid appearance. 

Adenoids often result in actual stupidity, because the 
child cannot get enough air. 

Adenoids often cause earache and deafness with some- 
times a running ear. Catarrh, deafness, earache and dis- 
charge from the ear, are more often due to some obstruction 
in the nose or throat than to anything else. 

Adenoids usually result in delicate health. 

Adenoids must be removed if you expect a child to be 
healthy or mentally bright. ■ 

It is an injustice to children to neglect caring for them 
when adenoids or diseased tonsils are present. It is very 
poor economy on the part of the parent to neglect the treat- 
ment of children so affected. Any child will grow up health- 
ier, happier, and more useful, if these conditions are taken 
care of. 



CHAPTER II 



DEFECTS OF VISION. 

Wliile most other defects tend to decrease in num- 
ber with age and development, defects of vision increase 
as one passes from tlie examination of the children of 
the lower to those of the higher grades in our schools. ^ 
A recent examination in the schools of New York 
city shows that about 30 per cent of the children suffer 
from various kinds of ocular defects which are serious 
enough to require correction. Of 400,000 pupils ex- 
amined in the schools of Massachusetts, 81,000 had 
defective ej^esight. iln the schools of Berkeley I have 
thus far found about 17 per cent with visual defects 
serious enough to need correction, while in a Poly- 
technic School in Pasadena, the proportion reached 
about 35 per cent in my tests during 1908. 

Eye strain results from various kinds of defective 
sight and carries with it sooner or later conditions 
which may seriously affect the nervous system. Many 
a case of nervous prostration or Neurasthenia has come 
to an individual in later life from such uncorrected 
faults of vision. Many a child in every large public 
school is today stumbling along the educational road, 
with vision so poor that he cannot read at 20 feet what 
a child with normal sight reads with ease at 200 feet. 

In nearly every schoolroom is found one or more chil- 
dren with "crossed-eye." Test this eye by covering the 

^Leonard Ayres has shown that in general "retarded" pupils 
are less defective than those unretarded, the explanation 
being that retarded pupils are older. 



32 The Health Index of Cphldren 

straight oue with a piece of card-board aud if the child 
is over eight or ten years of age, he cannot in the ma- 
jorit}-^ of cases tell the number of fingers held up at a 
distance of twelve feet from his face, and often such 
an eye is practically blind. Yet the early discovery 
of crossed eye and its complete correction with proper 
glasses will usually save the sight and often bring 
the eye around to its normal position. 

Poor vision not only makes the acquirement of an 
education a work of great difficulty, but it reduces the 
earning poiccv of the individual later in life very con- 
siderably. It is only through our special senses, of 
which sight is one of the most important if not indeed 
the primary, that we form anj' notions of the external 
world. All education in fact is acquired by means of 
the organs of special sense. Limit any one of these 
avenues of contact with the world and it is only by 
means of the over-development in acuteness in some or 
all of the other sense organs that the defect may be at 
least in part offset.^ Even then the result is usually 
quite imperfect and education becomes a difficult prob- 
lem. Limit or destroy any one of our avenues of con- 
tact with our environment and a definite receiving 
area of the brain is dimmed and blurred. Blurred 
vision for example, may mean a blurred visual area 
in the brain. Is it any wonder that children with such 
mental blurs often recpiire a longer period than a nor- 
mal child to finish a grade or that they complete their 
work only by the expenditure of an enormous amount 
of nervous energy? 

'The reader is referred to that remarkable and delightful 
little book by Helen Keller, "The World I Live in." 



Defects of Vision 33 

^'Education presupposes health." In the past poor 
vision has never been regarded as an indication of un- 
sound health. Today we know better. 

'The intimate relation betAveen muscle and nerve- 
center, the functional correlation of every organ with 
every other, cannot be too thoroughly grasped if a 
sound theory of training is to be built up." 

The Index of Eye-Defects. 

1. ''Sore eyes," or chronically inflamed eyelids. 

2. Styes. 

3. Congested (red) eyes. 

4. Crossed eye, occasional or constant. 

5. Holding book nearer than one foot from the 
face. 

G. Inability to read easilj' from the seat the Avrit- 
iug on the blackboard. 

7. Inability after ten years of age to read ordin- 
ary print at a distance of four inches from the face. 

8. Holding the book more than fifteen inches from 
the face. 

9. Squinting or blinking. 

10. Reading with the head turned to one side, or 
sloping the head. 

11. Headache. 

12. Usually poor readers and spellers. 

13. Avoidance of light. 

14. Hairless eyelids. 

15. Stooping posture. 

Some interesting and illustrative e^^e cases have 
come to my attention in the Berkelev and other schools 



ol The HEAi/rH Index of Children 

and are brieHy described here because it is evident that 
siniihir instances will be found in most schools. Only 
average cases hoAvever have been selected in the follow- 
ing illustrations. 

1. A girl of ten years was very nervous, complained 
of constant headache, and did very poor work in her 
studies. The parents were opposed to doctors and 
refused to allow the child to have her eyes examined 
or to receive any medical care. The case was reported 
to the Society for the Prevention of Cruelty to Child- 
ren and the i)arents forced to let the child have the 
necessary medical attention. Her eyes were exam- 
ined, the defect discovered and she was given proper 
glasses. Since wearing the glasses, her eyes and whole 
general condition have greatly improved, her headaches 
have disappeared and her mind is bright. 

2. A little boy nine years old had spent two years 
in the first grade He could neither learn to read nor 
spell, but he api)eared bright enough and was physi- 
cally well and strong. An examination of his eyes 
M'as made and it was discovered that the child could 
not read ordinary print six iiicJics away from his 
eyes. He was referred to an oculist at once and given 
proper lenses to correct his defective vision. In six 
months time this boy was reading as well as other 
children of his age, and was able to read some parts 
of the newspaper to his blind mother. 

Squint eyes or crossed eyes are found relatively 
often in our schools, but the seriousness of this defect 
of vision is rarely realized. Most often the condi- 
tion is regarded as a Monish, but nothing more. Par- 



Defects of Vision 35 

ents and teachers are astonished to discover that tlie 
crossed eye after eight or nine years of age and often 
earlier is sometimes nearly or qnite blind and fre- 
quently very greatly reduced in powers of sight. 

3. I observed tv^^o brothers about eight and ten 
years of age in one school both of whom had badly 
crossed eyes. A notice to the father brought him to the 
oflfice with the remark that he Avas perfectly familiar 
with the fact that his boj'^s were "cross-eyed" and didn't 
need a school physician to tell him so. "I would be 
glad," he said, "if^ my boys had straight eyes and were 
better looking, but Nature made them that way and I 
can't afford to spend money beautifying these boj'^s, 
so I guess they can worry along." This father was a 
Master Mechanic by trade, but was anxious that his 
boys should "do something better in life." In his 
judgment a clerkship was a more desirable position. 
I demonstrated to him that each of the boys was 
rapidly losing the vision in one eye and succeeded in 
showing hira that unless remedied the sight would be 
lost in the bad eye in each case. I then explained to 
him about how much this misfortune would reduce 
the future earning power of his boys. The father 
listened attentively, the commercial side of the argu- 
ment appealed to him, and he exclaimed : "Please send 
me to the nearest oculist, those eyes mvist be saved !" 

4. A boy of twelve years of age was reported by his 
teacher for examination because of a ^'sore-eye." A 
superficial examination at once showed a corneal ulcer 
of several da,ys standing, which had been entireh' neg- 
lected. This boy was an inmate of a high iclass 



30 The Health Index of Childuen 

eliildi-eii's home, yet his condition had never been ob- 
served by the Matron. Only immediate careful at- 
tention on the part of the oculist to whom he was re-" 
ferred saved the sight of the eye. Such oversight of 
serious i)hysical defects in this children's home was 
by subsequent examinations of other ])uj)ils from the 
same place found to be extremely common. Only the 
ordinary and most evident ailments of childhood re- 
ceived any attention here, despite the fact that a phy- 
sician was supposed to care for the health of the chil- 
dren. This state of affairs exists in most children's 
homes, as well as in reform schools and other institu- 
tions for juvenile offenders. 

5. A teacher in one of the lower grades had been 
complaining for a couple of years of extreme nervous- 
ness and general lassitude No eye symptoms of the 
usual sort had been observed by herself or by her physi- 
cian. She had a nund>er of times been on the verge of a 
nervous collapse and had been almost constantly under 
medical treatment. A routine examination of the eyes 
established the cause of the trouble. I'ronounced as- 
tigmatism existed. When this was corrected with 
pro])er glasses, all the nervousness and general de- 
bility disap})eared as if by magic and to her astonish- 
ment she could read signs and see other common ob 
jects from the street cars, which formerly she had sup- 
posed appeared blurred to ever^'one. 



Defects of Vision 37 

Resume on the Results of Uncorrected Defective Eye-tiight.l 

Defects of eye-sight in school children are very common. 
Probably at the lowest estimate 20% of the children of our 
American schools suffer from such defects. 

These defects not only cause a great deal of trouble in the 
eyes themselves, but often produce many other serious re- 
sults, vifhich do not at first seem to be associated with the 
eyes. 

The proper treatment of children's eyes will nearly always 
bring good results. In this way they will often be saved from 
life-long suffering. 

A child's education will not be worth much to him if he 
does not have good eye-sight. The ability to earn a good 
living depends very largely upon good eye-sight. It is very 
poor economy to neglect to care for defects in the eyes of 
children, for sooner or later such children may become bur- 
dens upon some one. The common defects of the eyes of 
children are as follows: 

1. Near Sight^ — (The eye is too long). 

This condition is very serious. It not only limits the child's 
range of vision and prevents his taking part in health giving 
sports and recreation, but it produces changes in the eyes 
which often result in practical blindness. 

2. Far Sight — (The eye is too short). 

This condition is more common than near sight. It results 
in eye strain and often causes squinting, red eyes, headache, 
nervousness, backwardness in studies, and sometimes digest- 
ive disorders and poor health generally. 

3. At3tigmatism — (Irregular curvature of cornea or lens). 
This is the most common of all eye defects. It results in 

blurred vision, headache, nervousness, and other* kinds of 
discomfort. It may be associated with either near sight or 
far sight. 

4. Cross Eyes or Squint. 

This is often the result of far sight. It is absolutely neces- 

•Published in pamphlet form for the use of the parents of 
the Berkeley school children. 



o8 The Health Index of Chh.duen 

sary to have this defect corrected. In children this can 
usually be done with glasses alone. If the trouble is not 
cured the vision of the crossed eye will often become poorer 
and poorer until at last this eye becomes practically blind. 

5. Inflamed or Red Eyes. 

This condition is often caused by a defect in vision, but fre- 
quently it is due to infection, that is something has gotten 
into the eyes and carried pus producing germs with it. 

Serious eye disorders are sometimes "caught" from dirty 
towels, public bathing pools, dirty hands, or dust. 

Each child and grown person should use his own towel. 
Red sore eyes ought never to be neglected. Remember that 
many cases of sore eyes are contagious and that all such 
cases need the attention of a doctor. 



CHAPTER HI 



DEFECTIVE TEETH. 1 

From 50 to 90 per cent of children in the grade 
schools suffer from defective teeth. ^ Dr. Osier has 
said that the intelligent consideration of dental hy- 
giene is of greater importance to a nation than that of 
the consumption of alcohol, great as that is. In most 
of our public schools, teachers are attempting to teach 
Physiology and Hygiene to pupils, the majority of 
whom possess mouths constantly unhygienic. 

If the Physiology and Hygiene of the mouth alone 
were practically and thoroughly taught, it would ac- 
complish far more good for the child than any amount 
of the usual perfunctory text book work. Children 
who recite excellent lessons in Hygiene frequently 
have conditions present in their mouths which are 
appalling. Let any teacher who doubts this state- 
ment examine even superficially the teeth of the pupils 
in an average grade and she will be convinced of the 
truth of this statement. Decayed teeth are a constant 
menace to a child's health. They furnish a lurking 
place for various sorts of dangerous bacteria. They 
constantly contain food which has undergone decom- 
position and which consequently furnishes toxins 
which are absorbed. Faulty states of nutrition, bad 
teeth, and enlarged lymph glands in the neck, are 

^Por some of the material and forms of expressions in this 
section the author acknowledges his indebtedness to the ex- 
cellent pamphlet called "The Why and How of the Teeth." 
Distributed by the Alameda County Dental Society. 



40 The Health Index of Ciih.dren 

conditions Avliicli usually accompany one another. 
Bad teeth cause bad digestion, and bad digestion often 
causes bad teeth. If you have one you are pretty 
certain to have the other. 

Many cases of Neurasthenia seem to be due at least 
in part to diseased teeth. Sir Frederick Treves, the 
ICnglish surgeon, states that over and over again it 
would appear as if the want of proper and efficient 
teeth had been the direct cause of attacks of appciidi- 
citis. Constipation, says Dr. J. II. Kellogg of Battle 
Creek, is the most common malady of civilization, ex- 
cept one — decay of the teeth — and the two disorders 
often go together. Without good teeth we cannot 
chew our food pro])erly, and the food is unfit for di-" 
gestion. The result is indigestion and constipation, 
poisonous decomposition by bacteria in the intestines, 
and liability to the whole brood of dangerous dis- 
eases — such as appendicitis, auto-intoxication, etc. — 
that come through wrong eating. To have good health 
we must masticate thoroughly and to masticate thor- 
oughly we must have sound teeth. 

One must never imagine that a child's temporary 
teeth can be safely neglected because a second set 
comes later. A child rarely has a good set of second 
teeth if the first have been neglected. It is exactly 
as important to care for the first teeth both personally 
and by means of the aid of a dentist, as it is to do the 

-In the Pasadena and Berkeley Hig-h Schools less than 3% of 
the students showed uncorrected defects of the teeth." Natural 
Selection" certainly plays an important part in eliminating the 
physically unfit from our schools, and to this fact at least in 
part is due the marked diminution of defects of the teeth in the 
his?her Schools. 



Defective Teeth' 41 

same for the permanent set. To neglect your chil- 
dren's first teeth is even a greater crime than to neglect 
your own, for it stores up endless misery for their 
later years of life. 

If systematic examinations were made of the 
mouths of the children in our public schools and if 
common sense dental hygiene were enforced, the death 
rate in this country would be very considerably re- 
duced, the amount of sickness decreased, and a strong- 
er race would result in consequence of such rather 
simple measures. 1 

The Index of Bad Teeth. 

1. Poor general nutrition. 

2. Prominent upper teeth. 

3. Inability to keep the mouth closed. 

4. Crooked teeth in sight. 

5. Decaj^ed teeth in sight. 
G. Offensive breath. 

7. Pallor. 

8. Enlarged lymph glands in neck. 

9. Tooth ache. 

10. Swollen face. 

11. Swollen gums. 

12. Sore gums. 

13. Indigestion. 

14. Excessive saliva. 

15. Acknowledgment of never having been to a 
dentist. 

16. Acknowledgment of not using a tooth brush. 

^Since the opening- of the Berkeley Dental Dispensai'y, an 
average of eighteen pupils per week have been cared for. 



42 The Health Index of Children 

17. Dirty looking teeth. 

IS. Receding gums. 

19. Some defects in articulation. 

20. Broken teetli.i 

When no school physician or school dentist is avail- 
able for conducting examinations, then the teacher 
or parent ought to observe the points enumerated 
above and if any of them are noted, consult a dentist 
at once. Every child ought to see a dentist every six 
months. "The money spent for one good (dental) 
house cleaning of one child at fourteen or eighteen 
exceeds the cost of keeping clean and in repair the 
teeth of the entire faniily when done systematically 
every few months." 

''The total time required to examine school children 
for teeth needing attention is much less than the time 
lost by absence from school or wasted at school on ac- 
count of toothache." 

'S^'ery often the temporary teeth are so badly neglect- 
ed that serious decay sets in. Under these conditions 
the roots do not properly absorb, and the second teeth 
are consequently pushed out of line by the obstruction 
formed by the roots of the first. This is one of the 
commonest causes of croolxcd teeth. Sometimes sec- 
ond teeth are in this way so crowded out of place 
that one or more appear in the roof of the mouth. 
A^lienever teeth erupt in a crooked manner they inter- 
fere with articulation, and sometimes to a very marked 
degree. Such teeth also seriously interfere with 

'Some of these points do not necessarily indicate bad teeth 
but they are suggestive of dental trouble. 



Defective Teeth 43 

])ropei' niaslication, and consequently^ with nutrition. 
If the first teeth decay early and come out, the second 
teeth will often appear much too soon and before the 
jaw is sufficiently expanded. This also results in 
crooked teeth. The effect of adenoids in causing 
crooked teeth has already been discussed in Chapter 1. 







^^KKS^t 


fl 








"^^M 


K^ ^% 


* * 


^# 


iSm 


wi^ r 


''^M 


^ 


iWI9f/^ 


p^ 




■k 


itt 


m ^"^^H 




■■■ 


^hhiihIh 


■l ',MM 




^HH 


flHJHIHH 



Three Portraits ShoAviiig the Iiin,'ro\ ement in Appearauce Due 
to Removal of Adenoids aud the Straightening- of the Teetli 

(By Permission of Dr. A. H. Sug-gett) 

Particular attention should be given to the sij^th 
year molars. These are nearly ahvays mistaken for 
temporary teeth, while as a matter of fact, they are the 
first permanent teeth. They can be easily recognized 
by remembering that they are the double teeth which 
appear in the mouth at the sixth or seventh year. Once 
lost they will never he replaced. 

Abscesses of the gums are met with very commonly 
in School Dispensary work. Nearly every dental case 
Avhich comes to the Berkeley Dispensary has either 



44 The Health Index of Children 

dead nerves or abscesses present. A dead nerve in 
time is always followed by abscess formation. 

In one school girl of fonrteen, twent}^ teetli were 
found badly decayed, and fonr of the molars were so 
nearly gone that extraction was necessary. Many of 
these teeth might have been saved entirely from decay, 
and the remainder preserved with small flllings if there 
had not been serious neglect of dental hygiene. 

It is not at all uncommon to find school dental 
cases with a dozen or more seriously decayed teeth. 
Hereditary Syphilis is occasionally observed in the 
Berkeley Dispensary as indicated by Hutchinsoniau 
teeth (notched front teeth). 

Some Cases of Dental Neglect. 

1. A child eleven years of age was sent to me for 
examination because of extremely poor physical devel- 
opment. An examination of the mouth showed an 
astonisliingly bad condition. .^lany of the teeth were 
badly decayed and the gums in several places were 
discharging i)us. This Avas a case of pyorrhoea due to 
neglected teeth. This little girl was suffering from 
constant sepsis, i. e. poisoning from the absorption of 
pus. The pulse in this case was 125 and the child was 
very nervous. A notice to the parents yielded no 
results and indeed produced nothing but offense. In 
such instances education must begin Avith the parents 
at home. 

2. A girl of about lliirleen was seen in another 
school, the condition of whose mouth and teeth beg- 
gared description Fringes of decaged first teeth sur- 



Defective Teeth 45 

rounded the second teeth Everywhere jms was dis- 
charging from the gnms The second teeth through di- 
rect infection from the first, were also seriously decay- 
ed, and fermenting food particles were everywhere pres- 
ent. Yet the condition of this child's teeth had never 
been observed by her teacher or by her parents Such a 
case requires careful attention just as much as does 
any other case of infection, yet our schools go on com- 
placently teaching ''Physiology and Hygiene" to hun- 
dreds of children whose mouths are constantly in 
nearly as bad condition as in the case Just described. 
3. Tn another school the principal sent to me for ex- 
amination a boy about twelve years of age, because he 
was supposed to have either an obstruction in the nose 
or defect of the teeth which interfered with his artic- 
ulation. It was almost impossible to understand any- 
thing this boy said and consequently he made very 
poor progress in school. Upon looking into his mouth 
I discovered that iiKjst of the hard palate tvas gone. At 
first I took this for an unusual case of cleft-palate, but 
further examination brought out the fact that this boy 
was suffering from hereditary sijiihilis with consequent 
destruction of the bones of the roof of his mouth. The 
cavities of the nose and throat opened into each other 
in such a manner as to form practically one cavity. 
Neglect of proper medical treatment had brought about 
this ulceration and final bone destruction of the mouth, 
most of which had occurred in the last eighteen 
months. Contrary to the usual opinions of the pub- 
lic, syphillis is usually curable if taken in time and 
vigorously treated for an extended period. In this in- 



46 The Health Index of Children 

stauce the child was pkiced under treatment to stop 
further ravages of the disease and sent to the San 
Francisco Dental Clinic, where a plate was fitted in 
his month which ett'ectually closed the great gap into 
the nasal cavity. The boy can noAv enunciate almost 
perfectly and will be able to make satisfactory pro- 
gress in school and later obtain employment, neither 
of Avhich could he have done in his former sad con- 
dition without treatment if indeed he had lived. 

If such various unhygienic conditions of the mouth 
just described do not offend the health standards of the 
community, they at least ought to olfeud their aesthetic 
standards. 1 

'I find that about iO'/r of the children in the grades have 
from fi\'o to ten decayed teetlr 



CHAPTER IV 



CONTAGIOUS DISEASES AND SCHOOL SANITATION. 

As a purely school commercial enterprise the con- 
trol of contagions diseases and proper attention to 
School Sanitation is an excellent business investment. 
iVttention to each of these conditions costs consider- 
able money, but in the end very much more money is 
saved for the school, the family, and the community. 
If one takes into consideration the amount of time lost 
hj school children through contagious diseases, and 
the consequent expense for medical attendance, to 
say nothing of the cost of lowered general vitality to 
the individual, the money value of sensible hygiene 
and sanitation in schools is at once evident. 

Every school ought to keep a very careful record of 
all its contagious diseases and then estimate how 
much loss results in appropriation (based upon aver- 
age daily attendance). As an interesting experiment 
let the school then attempt to discover about how 
much money is spent in one year for medical attention 
in contagious diseases among its school population. 
The results of such estimates would furnish argu- 
ments for practical health supervision which could not 
fail to appeal to the reason of all reasonable people.^ 

"We can read the index of '^catching' diseases," 
says Mr. W. H. Allen in Civics and Health, "before 
the outbreak that calls in the physician. School ex- 

^One of my students in the University of California has made 
a study of this problem in Berkeley. 



48 



The Health Index of Chh.dren 



amiuation shows which children have defects that 
welcome and encourage disease germs. It points to 
homes that cultivate germs, and consequently menace 
other homes. To locate children who have enlarged 
tonsils may prevent a diphtheria epidemic. To detect 




The Sanitary Driukiiig- Faucet' 

in September those who are under-nourished, who have 
bad teeth, and who breathe through the mouth (mouth 
breathers), will forecast winter's outbreaks of scarlet 
fever and measles. One dollar spent at this season 
in examination for soil hospitable to disease germs 
may save fifty dollars otherwise necessary for cure 
of contagious diseases. * * * Every teacher can 
be the sanitary engineer of her own school room or 

'The Haws Faucet. 



Contagious Diseases and School Sanitation 49 

school, by co-operating with the school doctor, the 
town board of health, family physicians, and mothers. 
* * * First she must know that 'children's di- 
seases' are not necessary. She should discountenance 
the old superstition that ever}^ child must run the 
gamut of children's diseases, that every child must 
sooner or later have whooping cough, measles, chicken- 
pox, mumps, scarlet fever, just as they used to think 
tj'phoid fever and malaria inevitable (in certain dis- 
tricts). The price of this terrible ignorance has been 
not only expense, loss of time, acquisition of perma- 
nent physical defects, and loss of vitality, but, for 
the majority of children, death before reaching five 
years of age. * * * The daily inspection of school 
children for contagious diseases by the school physi- 
cian (or competent teacher) has, where tried, been 
found to reduce considerably the amount of sickness 
in a town. The teacher should be conversant with 
the early signs of these diseases so that on the slight- 
est suspicion the child may be sent home witbout 
waiting for the physician's call (or the late symptoms 
of the disease). * * * The 'easy' diseases such 
as measles, whooping cough, etc., cost our communi- 
ties more than the more terrible diseases like typhoid 
and small-pox." 

Except for physicians, knowledge of the details of 
communicable diseases are rarel}^ necessary. For this 
reason only some general statements about them and 
an outline table of their main features will be pre- 
sented here. It must be understood also that gener- 
ally only those signs are indicated which appear early 



50 The Health Index of Chh.drex 

in each disease. In this manner confusion will i»e 
avoided and the way made clear for the teacher or 
parent to recognize any particular children's disease 
early in its course. 

Such early recognition of these diseases of child- 
hood will in many instances i)revent an cpidoiiir in 
the school or home and in the end save much time and 
money and prevent many serious sorts of complica 
tions, Avhicli often incapacitate the child for his fullest 
future usefulness and happiness. 

It will be well to keep in mind the following general 
facts in regard to children's diseases which are usually 
little understood, or if understood, very generally dis- 
regarded. 

The mouth is more often the place of entrance of con- 
tagious diseases than any other place. For this, among 
other reasons, particular attention should be given to 
the hygiene of the mouth. Decayed teeth undoubtedly 
favor the contraction of contagious diseases, not only 
so, but they harbor disease germs which may at any 
time, and particularly at periods of low resistance, at- 
tack the individual himself or be conveyed to others by 
means of coughing, exchanging food, pencils, books, etc. 

One ought especially to keep these facts in mind with 
respect to colds. Colds are probably about the most 
contagious form of disease we have, yet many, if not 
most people still go on regarding them as due to drafts, 
getting wet, to "night air'' and similar delusions. As a 
matter of fact anything which is capable of reducing 
our resistance makes it easy for cold germs to gain the 
ascendancy but the cold is directly due to the germ or 



Contagious Diseases and School Sanitation 51 



germs, and these causes should not be confused with 
the predisposing factors. "A cold can alwaj^s be 
charged to someone else. How many can be laid to our 
account? There is one right that is universally not 
recognized and that is the right of protection from the 




an open-air class 

(By Permission of Glen Taylor Private School, Alameda, Cal.) 

germs showered in the air we breathe and over the food 
we eat, in the school, street car, and at the restaurant. 
The chief danger of a cold is to our neighbor, and not 
to ourselves. A cold which a strong person may throw 
off in a day or two may mean death to his tuberculous 
(or otherwise debilitated) neighbor." 
Sometimes a single child with a cold may infect an 



52 The Health Index of Children 

entire class or all of his family. Before very long we 
shall no doubt exclude children with ''colds" just as 
we now do children with diphtheria. 

"The great preventive measure to be taken for catch- 
ing diseases — colds, diseased glands — in fact all germ 
disease, is the repeated cleansing of those portions of 
the human body in which germs find lodgment — tbe 
mouth, the nose, the eyes, and the ears." 

To this should be added that diseased tissues in any 
of these organs must be cured or removed, for such tis-: 
sue is a constant breeding place and focus of dissemin-; 
ation for disease germs. This is one of the strongest; 
arguments in favor of giving prompt attention to ad- 
enoids, diseased tonsils, discharging ears, sore eyes and 
bad teeth. Clean, healthy tissue can rarely if ever be 
infected with disease germs. 



Contagious Diseases and School Sanitation 53 



ci y, o 



_ C 0) 
j: ai a; 

01 3 C 



o o 
o O 



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c« 



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03 



Z os5K^argi;£g;ti 



5 cs 



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fo-M o c S 



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m«0 M - 
d i; .r-i +-> . 

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C to rt 

a 03 S 

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'Ao? 



03 



03 03 o 

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OS 



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54 



The Health Index ue Childuen 





oil 
(U >< o 


OJ 

^ a 

— W (2, 

t^ cS to 
o — 


Six to eight 
weeks or un- 
til desquam- 
ation has 
ceased. 








(0 

>-. 

OJ 

-r 




When children return, 
examine head for over- 
looked spots. All spots 
should have disappeared 
before child returns. A 
mild disease and sel- 
dom any after effects. 


Dangerous both during 
attack and from after 
effects. Great variation 
in type of disease. 
Slight attacks as infec- 
tious as severe ones. 
INIany mild cases not 
diagnosed and many 
concealed. The peeling 
may last six to eight 
weeks. A second at- 
tack is rare. When 
scarlet fever is occur- 
ring in a school, all 
cases of sore throat 
should be sent home. 




HZ 


1 to 

^^ . 

rt 3^ 

■a ^ <u 
OJ coj: 

o o c 
fc'^ o 


Forced exhala- 
tion, and dis- 
charges from 
nose and 
mouth, parti- 
cles of skin, 
and discharges 
from suppurat- 
ing glands or 
ears. Milk es- 
pecially apt to 
convey infec- 
tion. 




02 

JO 

«^ 
H 

s 


Sometimes begins with 
feverishness but is us- 
ually very mild and 
without sign of fever. 
Rash appears on second 
day as small pimple.s, 
which in about a day 
become filled with clear 
fluid. This fluid then 
becomes matter and 
then the spot dries up 
and the crust falls off. 
May have successive 
crops of rash until 
tenth day. 


The onset is usually 
sudden, with headache, 
languor, feverishness, 
sore throat, and often 
the child is sick. Usu- 
ally within twenty-four 
hours the rash ap- 
pears, and is finely 
spotted, evenlv diffused, 
and bright red. The 
rash is seen first on the 
neck and upper part of 
chest, and lasts three to 
ten days, when it fades 
and the skin peels in 
scales, flakes, or even 
large pieces. The 
tongue becomes whitish 
with bright red spots. 
The eyes are not wat- 
ery or congested. 






c3 
OJ ^ rf 
o I* o 



Contagious Diseases and School Sanitation 55 



-a 

<D 
CD !^ O 


Six weeks 
or until all 
diphtheretic 
gei'ms have 
disappeared 
If r o m cul- 
tures taken 
from throat 


Two months 
or until 
cough and 
V m i t i ng 
cease. 


O 1 u 


to 
-a 


to 

(D 
(D 




Very dangerous both 
during attack and from 
after effects. When 
diphtheria is occurring 
in a school all children 
suffering from sore 
throat should be ex- 
cluded. There is great 
variation of type, and 
mild cases are often not 
recognized but are as 
infectious as severe 
cases. There is no im- 
munity from further at- 
tacks. Fact of exist- 
ence of disease some- 
times concealed. Mem- 
brane may occur in nose 
only. 


After effects often very 
severe and the disease 
causes great debility. 
Relapses are apt to oc- 
cur. Second attack rare. 
Specially infectious for 
first week or two. If a 
child is sick after a 
bout of coughing, it is 
most probably suffering 
from whooping cough. 
Great variation in type 
of disease. 




Forced exhala- 
tion and dis- 
charges from 
nose, mouth 
and ears. 


Forced exhala- 
tion and dis- 
charges fro'm 
nose and mouth 


|1,C3 

m 


Onset insidious, may be 
rapid or gradual. Typ- 
ically sore throat, great 
weakness, and swelling 
of glands in the neck, 
about the angle of the 
jaw. The back of the 
throat, tonsils or palate 
may show patches like 
pieces of yellowish- 
white kid. The most 
pronounced symptom is 
great debility and lassi- 
tude, and there may be 
little else noticeable. 
There may be hardly 
any symptoms at all. 


Begins like cold in the 
head, with bronchitis 
and sore throat, and a 
cough which is worse 
at night. Symptoms 
may at first be veriy 
mild. Characteristic 
"whooping" cough de- 
velops in about a fort- 
night, and the spasm of 
coughing often ends 
with vomiting. 


m 
< 

cc 

M 
P 


Diph- 
theria 

• 


in 
o bD 



5G 



The Health Index of Children 



n '^ c 

0) ^ o 



■2j5'i> 



oo 



JO 

M 












m O 



0) bo Zl 
" = 55 0)3 
o.2^£§ 



C 4) 



3— p, 



^ 0) 



5 bi3 



01'-' +j cS 



>rt 



-o^r^-o 



oS c 



o ^ £ -'"O 
•^ S3 o * c 



O QJ 



■ £ P 
Jos.' 



a> <D 03 

m '^ w .t; ::; 

XttH •T'O O'— 
Pi < o; .-. -iJ ;2 



03 M C 

<o torn" 
P C ^ 3 

So^°g 
o c s 



•= o::^ 

0) to 
— C Oj 



^ 5^5 

"bim-aS 
1J 0) c o 
ffl C d cj 



— ^ 133 



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o _i "3 "2 - 

>S.- ^ - nS 



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lij X O C. 
^ (0 O to 1* 

, >^ 

, 0) 

to 



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"ti o oc, 






ift'O.^Si C <w 



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fa "-S o o. to 



^c'fe 



3^03 



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^£-=£co£ 

OJ !> -, dJrrt »-• 



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£=:=«* = 

_ o^ o£ o 



5 S'?.^ 






c.^ '^ 



03'" 
eo'O 

c« M S ■ 

t^ CO 03 I 

a;'0 



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CO ^^ O m CO , 



to O 






^5 



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*j J= ^ .- I' — ll) 
: ,n o >, ? ^ <i- 



Contagious Diseases and School Sanitation 57 



Tu^/"/ /^•"f". 




..A. 



DifltA.i-.V 




k/fi-Z-x Co.eh 



ucarlcf Ft-i 



.^1^ 



V/if 



Curves showiug prevalence in Berkeley of Typhoid Fever, 

Diphtheria, AVhooping Cough and Scarlet Fever, 

From 190G to 1910, Inclusive. 



58 



The Health Index of Children 



UAicken ro) 



Ay^^^v^ [:^. 





Ocourreuce of Cliickeu Pox, MiiiniKS, niul MeaMleiii iu Berkeley 

from IJtOO to IStlO. ScIiooIm ou^lit to know the exact 

status of their couta^ji-ious diseases at all times. 



Contagious Diseases and School Sanitation 59 




(1) — Curve indicating- average seasonal ocoiirrcnee of all Chil- 
dren's disease.*! in tlie Berkeley Sciiools for the years 1906- 
1010. Note that the curve reaches its height in March. 



'The charts here 
Mr. Ivan C. Hall. 



jiven were prepared under my direction by 



60 



The Health Index of Chh.dren 



Special Contagious Diseases. 1 
Contagious Eye Diseases. 

Attention has been called to the fact that children 
of school age are especiall}^ susceptible to general con- 
tagious diseases, but this is also true of diseases affect- 
ing the eyes. The early recognition of these eye 




The foniiiioii Fmioet Mlieii liiver<e«l Makes a Great Improve- 
ment on the t'ommou Drinkinj;' Cup and I'revents Contagion 

troubles is of very great importance, not only to the 
child atHicted but also to his intimate associates. 

As a rule a teacher is justitied in excluding any child 
or at least insisting upon a certificate from a physician 
whenever such a child is found with evidence of dis- 

'In the preparation of this chapter the author was materially 
aided by Dr. Geo. E. Tucker. 



Contagious Diseases and School Sanitation 61 

charging eyes, gluing of the eyelids or reddening of 
their inner surfaces, accompanied with any marked sen- 
sitiveness to light. To assist the teacher, parent, or 
any one else who has not had the medical experience, to 
distinguish the different contagious diseases of the eye, 
the following brief description of their essential char- 
acteristics will prove useful. 

(A). — Pink Eye — (Acute Catarrhal Conjunctivitis). 

This disease is of frequent occurrence among chil- 
dren and spreads in a school rapidly. It is commonly 
carried by means of the common wash basin or towel, 
borrowed handkerchiefs and the like. The child com- 
plains of smarting eyes, sensitiveness to light and a 
sensation as though sand were in the eyes. The eye 
lids stick together at night and there is often some vis- 
ible discharge in the corners of the eyes between the 
lids. The small blood vessels in the white part of the 
eyes (sclera) and of the lining of the lids (conjunctiva) 
are very prominent. This results in very noticeable 
reddening of the eyes. 

The disorder usually lasts from ten to fourteen days, 
but it may persist a much longer time. The trouble is 
easily cured if attention is received at once. 

(B). — Gonorrlioeai Conjunctivitis. 

This serious disease of the eyes is often found in new- 
born children, but it may also occur in children of any 
age or in adults. It is caused by the germ of Gon- 
orrhoea. 

Indications of this eye disease. 

1. One or both eyes may be affected. 

2. There is an intense inflammation of the eye-lids. 



62 The Health Index of Children 

3. There is a profuse, thick purulent discharge. 

4. The lids are red and swollen. 

5. There is usually intense i^ain. 

(). There is marked aversion to light. 

7. Tears flow profusely. 

This form of eye disease is most serious in its con- 
sequences, often causing blindness. It is highly conta- 
gious. For these reasons it ought to be recognized 
early and receive immediate and skillful treatment. 

The disease usually lasts from four to six weeks, but 
sometimes very much longer. 

Children with this eye disease must be kept carefully 
away from other children and every precaution used to 
prevent its spread by means of towels, handkerchiefs, 
wash-basins, the fingers and the like. 

(C). — Diphtheretic Conjunctivitis. 

This disease is due to the same germ which produces 
diphtheria in the throat or nose. It is very dangerous, 
but fortunately rather infrequent. The danger of con- 
tagion is very great, and therefore its early recognition 
is of the utmost importance in order to treat it proper- 
ly and prevent its spread. The essential characteristics 
of this complaint are : 

1. Severe pain in the eyes. 

2. Eye-lids tense and dark colored. 

3. Discharge at first thin and scanty, later thick 
and purulent. 

4. A thick, tenacious, greyish membrane forms upon 
the inner surface of the eye-lids which is very difficult 
to remove. 

The disease demands the same treatment as diph- 



Contagious Diseases and school Sanitation G3 

theria of the throat, and the period of exclusion and 
quarantine is of great importance. 

(D). — Trachoma. 

TJiis is the most serious disease of the eyes known. 
It is highly destructive and extremely likely to produce 
blindness. Trachoma is prevalent in certain foreign 
countries, especially in the Orient, and the United 
States has taken extreme precautions to prevent its 
introduction into this country. In California, tra- 
choma is most frequently found among Indians and 
Mexicans, and sometimes among the Japanese. In the 
large cities of the East and middle West, the disease 
often occurs among the children of other nationalities, 
largely in the slums or poorer districts. 

Those suffering from the disease must be immed- 
iately isolated and kept so until the disease has been 
cured. The principal characteristics of trachoma are: 

1. Inflammation is not very intense, but there is 
considerable swelling of the lids, an aversion to light 
and flowing of tears. 

2. The outer surface of the eye-ball becomes rough- 
ened. 

3. The inner surface of the eye-lids becomes covered 
with small granules, not unlike boiled sago grains in 
appearance, and this produces what is called granular 
eijc-lids. 

The disease is extremely contagious through the dis- 
charge from the eyes. Towels, basins, handkerchiefs, 
etc., are the chief means of conveyance, but uncleanly 
habits, unhygienic surroundings, poor food, poverty, 
and the like, favor its development and spread. Strict 



64 Tub Health Index of Children 

quarantine against this malady must be established 
and continued until all signs of discharge have ceased. 

(E). — Spring Catarrh. 

This eye disease is only mildly contagious. It occurs 
most often during the warm weather of spring. The 
chief symptoms are : 

1. Persistent itching. 

2. Pain slight or absent. 

3. Sensation of sand in the eyes. 

This is not a disease of very much importance, but is 
mentioned because it might be confused with the symp- 
toms of much more serious diseases. 

Conclusions. 

1. All contagious eye diseases must be recognized 
early. 

2. Removal from school of children with such dis- 
eases is necessary. 

3. Great care must be exercised to prevent con- 
tagion through the use of 

(a). The common toAvel. 

(b). The common basin. 

( c ) . Handkerchiefs, 

(d). Dirty fingers. 

fe). Bed-clothing. 

(f). Public bathing suits and possibly swimming 
tanks. 



Contagious Diseases and School Sanitation 65 

(II.) Contagious Disesvses of the Skin.l 
Scabies — The Itch. A contagious skin disease, due 
to an animal parasite wliich burrows in the skin, caus- 
ing intense itching and scratcliing. The disease usually 
begins upon the hands and arms, spreading over the 
whole hody, but does not affect the face and scalp. 
Between the fingers, on the front of the wrist, at the 
bend of the elbows and near the arm pits are favorite 
locations for the disease; but in persons of cleanly 
habits the disease may not show at all upon the hands, 
and its real nature is determined only after a most 
thorough and careful examination. There is a great 
variation in the extent and severity of this disease, lack 
of personal care and cleanliness always favoring its de- 
velopment. Scratching soon brings about an infection 
of the skin with some of the pus-producing germs, and 
the disease is then accompanied by impetigo, or a pus 
infection of the skin. 

At the present time itch is very common and wide- 
spread, and because of the great variation in its sever- 
ity, mild cases have been mistaken for hives, eczema, 
etc., the real condition not being recognized, and the 
disease spreads in consequence. All children who are 
scratching or have an irritation upon the skin should 
be examined for scabies. 

It is very important that all infected members of a 
family be treated till cured, else the disease is passed 
back and forth from one to another. It is also im- 
portant that all underclothing, bedding, towels, etc., 
things that come in contact with the body, be foiled 

'With acknowledgments to a pamphlet on Medical Inspec- 
tion by the Massachusetts Board of Education. 



G6 The Health Index of Children 

when washed. All cases of scabies should be excluded 
from school until cured. 

Pcdiculi Capitis — Head Lice. An extremely com- 
mon accident among children, either from wearing each 
others' hats and caps, or hanging them on each others' 
pegs, or from combs and brushes. No person should 
be blamed for having lice — only for heepituj them. 

The irritation caused by vermin in the scalp leads to 
scratching, which in turn causes an inrtammation of the 
skin of the neck and scalp. The skin then easily be- 
comes infected with some of the pus-producing germs, 
and large or small scabs and crusts are formed with 
the dried matter and blood. Along with this condition 
the glands back of the ears and in the neck become 
swollen, and may be very painful and tender. 

The condition of i>ediculosis is most easily detected 
by looking for the eggs (nits), which are always stuck 
onto the hair, and are not readily brushed off. The 
condition is best treated by killing the living parasites 
with crude petroleum, and then getting rid of the nits. 
With boys, this is easy — a close hair cut is all that is 
needed ; with girls, by using a flne-toothed comb wet in 
alcohol or vinegar, Avhich dissolves the attachment of 
the eggs to the hair. All combs and brushes must be 
carefully cleansed. 

Children with pediculosis should be excluded from 
school until their heads are clean. In Massachusetts 
since 1906, parents who neglect or refuse to care for 
their children in this respect may be prosecuted under 
the compulsory attendance law. 



Contagious Diseases and School Sanitation 67 

Ringworm. A vegetable parasitic disease of the skin 
and scalp. When it occurs upon the skin, it yields 
readily to treatment; but upon the scalp it is extreme- 
ly chronic. Ringworm of the skin usually appears on 
the face, hands or arms, rarely upon the body — in vary- 
ing sized more or less perfect circles; One or more, 
usually not widely separated, may be present at the 
same time. All ringed eruptions upon the skin should 
be examined for ringworm. 

When the disease attacks the scalp, the hairs fall or 
break off near the scalp, leaving dime to dollar sized 
areas nearly bald. The scalp in these areas is usually 
dry and somewhat scaly, but may be swollen and crust- 
ed. The disease spreads at the circumference of the 
area, and new areas arise from scratching, etc. 

Another disease, somewhat like ringworm of the 
scalp, is known as favus — a disease much more common 
in Europe than America. In this disease quite abund- 
ant crusts of a yellowish color are present where the 
process is active. The roots of the hairs are killed, so 
that the loss of hair from this disease is permanent, a 
scar remaining when the condition is cured. 

Care must be taken to see that all combs and brushes 
are thoroughly cleansed, and to prevent children wear- 
ing each others' hats, caps, etc. Children with ring- 
worm should not be allowed to attend school. 

Impetigo. A disease characterized by few or many 
large or small flat or elevated pustules or festers upon 
the skin. The condition is often secondary to irrita- 
tion or itching diseases of the skin (hives, lice, itch), 
and scratching starts up a pus infection. 



68 The Health Ixdex of Ceiildren 

The disease most often appears upon the face, neck 
and hands ; less often upon the body and scalp. The 
size of the s})ots varies very much, and they often run 
together to form on the face large superficial sores, 
covered with thick, dirt}^, A'ellowish or brown crusts. 
The disease is contagious, and often spread by towels 
and things handled. Children having impetigo should 
not be allowed to attend school until all sores are 
healed and the skin is smooth. 



Contagious Diseases and School Sanitation 69 

Sanitation of Schools. 
The subject of School Sanitation is far too compre- 
hensive to treat at all completely in a book of the scope 
of this one ; moreover, there already exists a number of 
excellent works on this subject which are accessible for 
teachers. For this reason only some general features 
of School Sanitation will be j^resented and more es- 
pecially those which ought to come rather directly 
under the observation and control of the teacher than 
of the sanitary oflScer. The whole subject from the 
teacher's point of view may be profitably presented in 
the form of a "Sanitary Survey." Such a survey ought 
to be intelligently undertaken by every conscientious 
and efficient teacher in a public school. The questions 
under I (A) should be ansAvered by teachers, the re- 
mainder by the Principal. 



Sanitary Survey of a School. 1 



I. BUILDING. 



A. School Room. 


Yes 


No 


1. Is damp sweeping- practiced? 






2. Is" a moist cloth used for wiping- up dust? 






3. Has the feather duster been abolished? 






4. Is any disinfectant used upon the floors? 






5. Are the desks cleaned with a disinfectant? 






6. Are the school books disinfected when 
necessary? 






7. Is the common use of articles which might 
carry infection avoided? 







Use a check to answer the questions. 



70 



The Health Index of Children 





Yes 


No 


8. Has a list of such articles been made up? 






9 If a "Plenum" or other system of artificial 
ventilation is used is it in good working 
order? 






10 Are some of the windows always thrown 
open if the motor is not in operation? 






11. If an artificial system is not used are some 
' of the windows always kept open both 
from the top and the bottom? 






12. Are ventilation boards fitted in under the 
lower sash? 






13. Are all the windows thrown open at recess? 




14. Have desks been re-dressed within two 
years? 






15. If a stove is used in the room does it have a 
••jacket" around it and is there special 
arrangement for ingress and discharge 
of the air from the room? 






16 If a furnace is used does the air-box con- 
nect directly with the outer air, and is 
outer opening kept free from dirt, leaves, 
snow, etc.? 






17. Is some arrangement made to keep the air 
of the room sufficiently moist? 






18. Is the fresh air inlet removed from toilets 
or other sources of contamination? 







19. Is the room free from unpleasant odors at 
all times? 




20. Are dustless crayons used? 






21. Are green or brown flat finish boards used 
instead of glossy black? 






22. Are erasers cleaned thoroughly every day 
out of doors? 






23. Are the floors oiled or otherwise treated to 
prevent dust rising from them? 






24. Is the room temperature kept even? 




25. Is is kept under 70 degrees and over 60 
degrees? 





Contagious Diseases and School Sanitation 71 

Yes No 



26. Do the windows have an area equal at least 
to one-fifth the floor area? 






27. Are the desks so placed as never to face 
direct sunlight? 






28. Is the room evenly lighted? 






29. Are dark window shades avoided? 






30. Are white shades avoided? 






31. Are yellow or linen colored shades used? 






32. Is the tinting of the walls light enough? 






33. Are neutral colors used? 






34. Is the ceiling lighter than the walls? 






35. Is over decoration avoided? 






36. Are the seats adjustable? 






37. Are the desks adjustable? 






38. Are they adjusted? 






39. Are wooden footstools provided where the 
seats cannot be adjusted? 






40. Is a light, dry, clean, ventilated room pro- 
vided for clothing? 






41. Is over-crowding of pupils avoided? 






42. Are deaf pupils seated near the front? 






43. Are pupils with defective vision seated near 
the front? 






44. Are pupils with skin diseases excluded? 







The Health Index of Chh.dren 

Yes 



No 



■ 

45. Are pupils with lice excluded? 






46. Are contagious diseases recognized early? 


47. Is strict exclusion practiced in contagious 
diseases? 






48. Are certificates from physicians required 
for re-admission? 






49. Is successful vaccination required? 






50. Are ordinary physical defects looked for 
and recognized easily? 






51. Are parents notified of the presence of de- 
fects? 




52. Are mentally defective pupils excluded? 






53. Are children with fits excluded? 






54. Are children with St. Vitus Dance excluded? 






55. Is there medical supervision of pupils? 






56. Is there medical inspection of buildings? 






57. Are the windows screened? 






B. Halls. 






1. Are the halls clean? 






2. Are floors properly prepared to keep them 
free from dust? 




3. Are halls well lighted? 




4. Are they well heated? 




5. Is liquid soap provided in hall wash basins? 



Contagious Diseases and School Sanitation 73 

Yes No 



6. 


Are sanitary drinking faucets or fountains 
provided? 






7. 


Has the roller towel been abolished? 






S. 


Has the common drinking- cup been abol- 
ished? 






9. 


Are the halls well ventilated? 






10. 


Are exits plentiful and unobstructed? " 






11. 


Are stairs wide and straight? 






12. 


Are the halls free from obstructions? 








C. The Basement. 

Are the floors clean and dry? 






1. 






2. 


Are they of cement? 






3. 


Are wash basins and sinks clean? 






4. 


Are individual towels provided? 






5. 


Are there any shower baths? 






6. 


Are toilets clean and well ventilated? 






7. 


Is the plumbing modern? 






S. 


Is the air wholesome? 






9. 


Are toilets well shut off from air intakes? 






10. 


Are sanitary faucets or fountains provided? 






11. 


Is the ventilation and heating apparatus 
in order? 















74 



The Health Index of Children 





Yes 


No 


11. THE GROUNDS. 






1. Are the play-grounds large and adequate 
for the number of pupils? 






2. Are they well drained, dry and even,? 






3. Is there any play-ground supervision? 






4. Is play apparatus provided? 






5. Are some open air rooms provided for play, 
rest, lunch, protection from weather, 
and for recitations? 




6. Are the grounds well separated from un- 
desirable neighbors? 






III. GENERAL SANITATION. 


• 




1. Is a lunch room provided for teachers? 






2. Is one provided for pupils? 






3. Do the lunch rooms have tables? 






4. May a hot lunch be obtained? 






5. Is there a pleasant rest room for teachers 
and pupils? 






6. Is there an "emergency" outfit provided? 






7. Is instruction given on how to use such an 
outfit? 






8. Is practical hygiene taught? 






9. Is individual cleanliness insisted upon? 






10. Have the teachers been taught how to de- 
tect ordinary physical defects? 






11. Is practical dental hygiene taught by actual 
observation of the teeth? 







Nervous Disorders of Children 



Yes 



75 

No 



12. Is there any personal inspection of pupils? 






13. Is school credit given for neatness and 
cleanliness? 






14. Are older pupils taught to make simple 
sanitary surveys of what they see at 
stores, shops, homes, parks, dairies, on 
the streets, etc? 






15. Is any inspection ever made of pupils' 
lunches? 






16. Are pupils encouraged to inspect them- 
selves and their own environment to 
detect errors? 






IV. THE ENVIRONMENT OF THE SCHOOL. 

1. Is the ground well drained? 










2. Are tin cans and other receptacles in which 
rain water might collect kept picked up? 






3. Are other breeding places of mosquitos de- 
stroyed? 






4. Is garbage of all kinds properly destroyed? 






5. Is manure and other refuse hauled away as 
fast as it collects? 






6. Are family garbage cans kept covered? 






7. Is it thoroughly understood at your school 
that all refuse of the above sort fur- 
nishes breeding places for flies? 






8. Is the air in the neighborhood of the school 
clean and free from an excess of gases, 
dust and smoke? 






9. Is your drinking water from a safe source? 






10. Does your school understand just how a 
school drinking water supply may be- 
come infected with sew^age? 






11. Are you relatively free from flies? 






12. Are vacant lots kept clean? 







CHAPTER V. 



NERVOUS DISORDERS OF CHILDREN. 

Nervous disorders in school children are no doubt 
largely of the functional sort but nevertheless they are 
of the utmost importance and of relatively frequent 
occurrence. Other and more serious nervous disorders 
are not very common and yet are to be found to some 
extent in nearly every large school. 

A wise, sympathetic understanding of children and 
their ways is a rather rare quality both among parents 
and teachers, and it is precisely this lack of intuition 
in dealing Avith children which so often results dis- 
astrously for the child. Children are mostly all alike 
in one respect and that is that they are so different. 

These differences are often so subtle in character 
that numy of them are not recognized at all by teacher 
or parent, yet it is the clear recognition of such dif- 
ferences and the adaptation of educational and correct- 
ive methods to them which will result in success or 
failure for the pupil. 

Nervous, irritable children in many cases have nerv- 
ous, irritable fathers or mothers. Often it is quite 
hopeless to attemi>t to correct these conditions in chil- 
dren unless the unfavorable home environment can be 
changed or at least modified. Parents, teachers, and 
even physicians dealing constantly with children have 
in the past usually paid too little attention to child 



Nervous Disorders of Children 77 

nature. They have all very generally interpreted chil- 
dren's ways b}^ the standards of grown-ups. 

''It is difficult to understand," says Dr. Leonard G. 
Guthrie, ''why a subject so important to the welfare of 
the communit}^ as the study of children should have 
been so long neglected in this country (England). 

"P.erhaps the public as well as the medical profession 
are to blame. For from time immemorial the upbring- 
ing of children has been regarded from an economical 
rather than a medical point of view. Many an elab- 
orate treatise on methods of training children to be 
healthy, virtuous and brave has seen the light, but has 
emanated from moral educationalists and not from 
physicians. In fact, medical men were not supposed 
to interfere in matters considered to be outside their 
province. If children were ill or ailing the doctor was 
called upon to prescribe for their diseases, but advice 
on their management in general was neither sought nor 
welcomed. 

"He was not asked to see a child because it was way- 
ward, but because it was wasting, not because it was 
dainty, capricious in appetite, refusing food considered 
good for it, and craving for all that is unwholesome, 
but because it had pain in its stomach. Advice was 
not asked for peevish, passionate children, nor for 
those who Avere afraid of the dark, and unnaturally 
timid, absent-minded, or brooding and morose, jealous, 
spiteful, or cruel, nor for mischievous, untruthful, dis- 
honest, or immoral children. All such defects were 
regarded as moral rather than morbid, and were treat- 
ed as such. It was long before it was recognized that 



78 The Health Index op Children 

a cliild might be dull and stupid in consequence of de- 
lects of sight or hearing." 

It is still much the same in our schools today. 
Schools are largely without medical supervision and 
the various degrees of peculiarities and so-called mis- 
behavior among school children are consequently re- 
garded on the part of teachers from the moral and 
educational rather than the physical point of view. 
The nervous disorders ordinarily met in school chil- 
dren are the following: 

1. Chorea, or St. Vitus Dance. 

2. Habit Spasms. 

3. Neurasthenia, or Nervous Exhaustion. 

4. Epilepsy. 

5. Hysteria (not common). 
i). Stammering. 

7. Migraine, or Sick Headache. 

8. Sex Disturbances. 

Chorea. 

It is most important to recognize chorea or St. Vitus 
Dance early. As a matter of fact, this disorder is rare- 
ly recognized until it is well advanced. Any child 
should be suspected of developing chorea, who has the 
following habits : 

1. Kestless. 

2. Purposeless motions. 

3. Inability to hold pencils, books, knife, fork, etc., 
securely. 

4. Falling down easily and frequently. 



Nervous Disorders of Children 79 

Parents, teachers, and some phj'^sicians often fail to 
recognize chorea until the spasmodic symptoms occur. 
These include muscular spasm of various parts of the 
body, such as contortions of the face, jerking move- 
ments of the head, shoulders, arms and legs. 

It is most important to recognize Chorea early as it 
is often, if not always, closely associated with rheu- 
matism, and in such cases the heart is very frequently 
affected. 

Children with developing chorea are highly excitable 
and it is therefore most unfortunate that they are so 
often misunderstood, and perhaps scolded and pun- 
ished for misbehavior, when in reality they require the 
most patient and kind sort of treatment. 

Children with this disorder ought to be removed from 
school both for their own good and for the good of 
other pupils, some of whom are very likely to imitate 
their grimaces and other habits until it becomes a fixed 
habit in themselves. Children with this nervous affec- 
tion require long rest, quiet life and the most careful 
medical treatment. 

Habit Spasms. 

Many nervous children develop habit spasms, which 
are characterized by quick, involuntary, peculiar move- 
ments. They may be easily recognized by the following 
description by Dr. Guthrie : 

"A series of lightning-like blinks or nods or sudden 
turns of the head aside. The eye-brows may be elevated 
or corrugated or the upper lids may be raised several 
times in quick succession as in a munching rabbit, or 
the nose may be wrinkled and the nostrils expanded or 



80 The Health Index of Children 

contracted whilst half a dozen or more little ineffectual 
sniff's are produced, or a variety of grunts and queer 
guttural noises are heard. 

The characteristic of all these simple tics is that 
they suddenly come and go, and each form will com- 
monly give place to another. It is seldom that more 
than one trick or antic is present at a time." 

In a more complicated form of habit spasm or tic the 
child will often perform the most astounding tricks. 

'"For instance, after spending some days or weeks in 
repeating apparent efforts to twist his mouth around 
his nose, the child will suddenly relinquish the attempt 
and take to elevating his chin and stretching his neck 
as though his collar were too tight or he will shrug his 
shoulders or writhe like an eel at short intervals; or, 
whilst walking will suddenly execute a twirl, a hop, 
skip or jump, or he will stamp heavily on the ground 
with one or both feet or strike his head or body vig- 
orously with his fist. 

''One child under observation would at half-minute 
intervals shut her eyes tightly, show her teeth in a dis- 
agreeable snarl, and protrude her tongue with vibra- 
tion like a snake. 

Children will often lament bitterly that they cannot 
overcome their "habits,'- and each time they acquire a 
new one they will mournfully announce the fact to 
their sorrowing next of kin. Sometimes they occur 
only when the child knows he is watched, in other 
cases, only Avhen he believes himself unmolested." 

The present writer recently observed at a family 
dinner a parent and four young children all victims of 



Neuvous Disorders op Children 81 

tics or habit spasms in a mild degree. He remembers 
very Avell that the parent had these habit spasms as a 
school boy in a much more aggravated form and that 
several other members of his friend's family including 
his own father, three brothers and a sister, were all 
afflicted somewhat. 

A patient of the writer's some years ago had ac- 
quired a peculiar form of tic w^hich consisted in sioal- 
lotving toind and then belching it forth with illy con- 
cealed but strenuous efforts to avoid detection. These 
strange, grotesque, subterranean sounds often dis-t 
turbed the peace of mind of his immediate associates 
at social functions. 

The importance of correcting such unfortunate hab- 
its during the impressionable period of youth will thus 
be seen to be most desirable. 

Neurasthenia or Nerve Strain. 

Nervous exhaustion or neurasthenia is not a disorder 
enjoj'ed exclusively by the idle rich. While common 
enough among this class of adults, it affects all classes 
of people and even children. Many such children have 
passed through nervous horrors during several years of 
their lives Avliile their parents and teachers were quite 
unconscious of any condition existing more serious 
than "nervousness" or natural ^'perversity." Many 
neurasthenic children suffer torments yet are entirely 
unable to explain their situation to relatives or friends 
or even to appreciate in the least what is the matter 
with themselves. The writer has a friend who as a boy 
suffered in this way for at least five years in total 



82 The Health Index of Chh.dren 

silence, and it Avas only as a young man that he 
finally nnburdened himself to an older and sympathetic 
brother. This boy progressed normally enough through 
the first six grades of the public schools. Then at about 
the age of twelve, the beginning of puberty, he began to 
develop various signs of nervous exhaustion. 

Audit(U"y disturbances first afilicted liim. Voices 
and other sounds seemed often to be hollow, muffled, 
monotonous, and far away. His own voice sounded 
the same to him. This condition was often present for 
days at a time and continued for several years with 
only slight intermissions. This distressing symptom 
was almost unbearable and the boy often thought he 
was losing his mind. In fact by the time he Avas fifteen 
years old he was (juite fixed in that belief. Sleep was 
fitful, unrefreshing, and finally at thirteen years of age 
disturbed with erotic and exhausting dreams which 
the child could not in the least comprehend. 

These sexual dreams* which in moderation are nor- 
mal enough to every growing boy had never been ex- 
plained to him and constantly preyed upon his sensitive 
conscience, and this unfortunately reacted in the worst 
possible manner causing more nervous instability dur- 
ing the day and increased frequency of the sex dreams 
at night. He was now more than ever convinced that 
he Avas losing his mind and the victim of some sort of 
evil for which in a dim sort of way he considered him- 

*Thls matter is mentioned here because boys are seldom 
informed by their parents about such matters and because 
most of them are greatly alarmed about the occurrence of such 
dreams until they understand their nature. Sensible instruc- 
tion about the ag-e of puberty in such matters is absolutely 
essential to the peace of mind and even health of the average 
child. 



Nervous Disorders of Children 83 

self responsible. His habits, however, were most ex- 
emplary and he lived conscientiously to the last degree 
Of his knowledge. He had indeed a morbid 'iNew 
England conscience." 

The child soon fell by the wayside in school. His 
studies became uninteresting and diflBcult for him. He 
lost a grade and this filled his cup of sorrow and hu- 
miliation to the brim. Self confidence began to wane, 
he took little interest in active sports, his health began 
to fail, he was anaemic, thin, and always tired. Ring- 
ing and buzzing sounds added their torments to his 
other troubles. He was almost constantly disturbed 
with an excessive flow of saliva and with an almost 
insane desire to keep swallowing it (a habit of spasm). 
He became weak, tired, full of indefinite pains, un- 
happy, apprehensive, miserable. Yet despite all of 
these afflictions so heavily laid upon his youthful shoul- 
ders, he managed to present a fair front to his asso- 
ciates, family and teachers. He did not attempt to 
avoid company and seek solitude; he took his part as 
far as he could in boys' games tho' never succeeding 
very well with them. He was regarded as a delicate, 
sensitive boy, but not as morose, or melancholy, or the 
victim of any very unusual troubles. He belonged to 
the c^ss of neurasthenic children called the '^Re- 
strained Emotional Type." 

In this type, as Dr. Guthrie remarks, emotions are 
very strongly felt, but the powers of control are equally 
strong. They are (usually) solitary in habit, intro- 
spective, prone to self analysis, imaginative, with mor- 
bid love of horrors, and equally morbid dread of them. 



84 The Health Index of Children 

They may harbor various kinds of fears and sometimes 
develop abnormally conscientious scruples of moral 
and religious nature. 

This disposition, Avith its characteristic suppres- 
sion of outward display of emotions is as exhausting 
as that of the other type (the unrestrained emotional 
type) in which emotional excess is obvious, and is 
associated with many similar complaints. 

In the case of the boy described it was not until in- 
creasing years had brought him to the point of seeking 
advice that his symptoms finally cleared up. For- 
tunately for him he possessed a father who Avhile en- 
tirely unconscious of his boy's real sorrows and 
troubles, yet possessed a wholesome kind of insight and 
common sense which led him to keep the child out of 
doors as much as possible. He removed him from 
school, employed him at light labor part of the time to 
occupy his mind and aid him in his physical develop- 
ment, furnished him Avith opportunities for horseback 
riding, rowing, sailing, camp life, and some traA'el. 
I^jxcept for this fortunate help from an unusually intel- 
ligent and kind though medically uninformed parent, 
this boy might easily haA'e passed, into a mental and 
I'hysical decline ending A'ery likel}' in tuberculosis or 
permanent melancholia. As it was he entireh' re- 
covered at about eighteen years of age. 

Now the case just described in considerable detail 
may seem to the reader rather unusual, yet Avitli minor 
differences it is a certainty that a A'ery considerable 
number of the boys and girls in our schools are victims 
of such unhappy disorders caused by nervous exhaus- 



Nervous Disorders op Children 85 

tion. Many pupils like the one just described acquire 
an amount of self control and reserve which is quite out 
of proportion to the burdens they bear, and they con- 
sequently successfully hide from their associates the 
real troubles through which they are passing. 

Nervous children need the utmost care both at home 
and at school. They need a firm but sympathetic hand 
to guide them. Someone must get their confidence and 
encourage the unburdening of the little mind so cloud- 
ed with new and strange thoughts and sensations which 
the child so little comprehends and so greatly fears. 

Months or years of untold, unnecessaiw suffering can 
in this way be prevented, and timid, sufl'ering, unhappy 
children led into the normal, happy, wholesome life 
which is the birthright of every child.^ 

Epilepsy. 

In this disorder there is loss of consciousness and 
there may or may not be convulsions. Children who 
show signs of marked inattention, forgetfulness, 
dreaminess, great irritability and uncontrolled pas- 
sions, ought to be kept under observation with the 
possibility of developing epilepsy in view. Children 
with early symptoms of epilepsy are also likely to be 
subject to headaches, disturbed sleep, night terrors and 
spasms. 

Sometimes children have an attack of epilepsy which 
very much resembles fainting. They will grow pale, 

'It is important to remember that Neurasthenia, better called 
Nerve Strain, nearly always has a perfectly definite cause 
which ought to be discovered and corrected as early as pos- 
sible, and that a great number of factors must be considered 
in determining the cause in different cases and various tem- 
peraments. 



86 The Health Index op Children 

become dazed, stop talking, stand or sit perfectly still, 
aud lose consciousness for a moment, though the last 
symptom may not be observed and the child may be 
quite oblivious of his condition in this respect. 

In more serious cases the child has a "fit" as it is 
ordinarily called. He falls down in a spasm, with 
frothing at the mouth. Following the attack a deep 
sleep usually comes upon him. Sometimes he will 
have no recollection of the attack. 

Nearly every large school that I have examined has 
had at least one epileptic pupil in it. These cases 
ought to be recognized by the teacher, aud the pupil 
])romptly removed from school. Epileptics have no 
place in our public school system both for their own 
sake and the sake of other children who are terrified at 
the sight of their -fits. Sooner or later chronic epilepsy 
is likely to result in mental deficiency. 

Cases of epilepsy in which the attacks are infrequent 
and do not occur at school often produce results which 
are attributed to pure perversity and maliciousness. 
I have lately seen a boy who displays at school, as the 
only sign- of this disease, general insubordination and 
slow progress in the school room, and uncontrolled fits 
of anger with stone throwing and fighting on the play- 
ground. Considerable mental deterioration has al- 
ready occurred. 

Such pupils are sometimes very dangerous com- 
panions for the other children. In their anger they 
are likely to seize any object without the least dis- 
crimination, a rock, a hatchet, a shovel, or the first 
thing which comes to hand, and hurl it at the innocent 



Neuvous Disorders op Children 87 

but offending child. Special school homes ought to be 
provided for epileptics in every state.^ 

Hysteria. 

This disorder except in very mild forms is not found 
very commonly among school children. So-called 
hysterical manifestations, such as undue weeping, 
laughing, feigned illness, and the like, are not hysteria 
at all, but indications of a high strung, uncontrolled 
neurotic temperament. 

General Nervous Instability. 

In every large group of children there can always 
be discovered a considerable number who, while free 
from any definite nervous disease, yet deviate to a 
marked degree from the state of the normal child. 
Such children are restless, inordinately active, busy 
to no very definite purpose; their emotional natures 
are often undulj^ developed and under very poor con- 
trol. Laughter and tears are always near the surface. 
Affection, anger, sorrow and joy are not very well dif- 
ferentiated. Tlie}^ are inclined to selfishness, fond of 
attracting attention, quick to give offense, but quicker 
to resent it in others. They are usually bright and 
affectionate, but irritable, passionate and emotionally 
uncontrolled. Dr. Francis Warner says of this type— 
"They are the children who are delicate without hav- 
ing any disease ; who are rarely laid up with any defin- 
ite illness, but are not strong; they cannot walk far 

'Some of the worst crimes on record have been committed by 
Epileptics. In the criminal code of Ancient Rome the possi- 
bility of Kpilepsy as a factor in crime received important con- 
sideration. 



88 Tiiio Hi<:altii Index of Ciiilduen 

without getting tired; the}^ are capricious in appetite, 
yet sometimes ravenous, but remaining stationary or 
increasing slowly in weight.^" 

At home children of this type are usually very badly 
disciplined and indeed such children often furnish a 
pretty fair index of the character of their parent or 
parents. Such parents use little discretion in matters 
of discipline. They cannot bear to see the child cry. 
Since the child never meets with resistance, it wishes 
to possess everything that it sees. It wants every 
whim and cai)rice satisfied. It knows its strength ; it 
knows what its tears will accomplish, and as a perfect 
tyrant it abuses its power to desire everything and to 
do everything Avhich it should not do. In the end 
this sort of home training, or rather the lack of it, 
develops the typicall}^ nervcms, unstable, tyrannical 
child. He not only becomes a source of annoyance to 
others, but defeats his own happiness for he never 
learns the habit of self control. As an adult this type 
furnishes a large proportion of those who go about in 
the search for itnearncd happiness, a happiness Avhich 
they, of course, never secure. 

Many neurasthenics among adults appear to have 
passed through a childhood of the sort just described, 
and indeed their neurasthenia has often resulted di- 
rectly from their faulty early methods of training. 

Most "nervous children" need definite, rigid home 
discipline, and in many instances such training might 
will begin with the ]>arent. "Such children should be 
taught to endure pain with some degree of self control. 

iThe Study of Children (Warner)- 



Nervous Disorders op Children 89 

to respect the rights of others, to obey just commands, 
to acquire some degree of composure, to live regular 
lives, to be unselfish and to love the good, the true and 
the just. This constitutes a strong point in the battle 
against the conditions which threaten nervous stabil- 
ity. Love of fellow-man, unselfishness, and a feeling 
for the welfare of others, a strongly developed feeling 
of duty — these qualifications fortify one most surely 
against that egotism which leads to nervousness. Par- 
ticularly high in these qualities is the love of truth. 
He who is true to himself and others is rarely over- 
taken with a disorder whose striking characteristics 
are ''exaggeration and dissatisfaction." ^ 

One of the most difficult problems presented for 
solution in the physical study of school children, is 
how best to correct the faults which begin at home. 
After all, it is here that the most essential parts of a 
child's education should be acquired, and no school 
has done its full duty to the child which makes no at- 
tempt to carry education when necessary directly into 
the home. To illustrate how such home education 
may be accomplished, some cases from my own exper- 
ience are related here. 

Irritability and nervousness among children appear 
to be constantly increasing, and this is true whether 
we consider the children of the city or the country; 
the children of this country or of other highly civil- 
ized, and therefore complexly organized countries. 
One of the penalties of life in highly developed society 

^Dr. I. A. Atat, in an address entitled, "Nervous Children," re- 
printed from the Lancet-Clinic. 



90 The Health Index of Children 

is this increased tendency toAvard nervous instability. 
For this state of affairs parents are to a considerable 
extent to blame, for the habit of nervous instability 
is largely acquired in childhood. The child has the 
right of protection against the constantly increasing 
wear and tear of complex social conditions, and the 
right of proper education to enable him to cope with 
his increasingly difficult environment. 

Heredity, predisposition, and environnnent .deter- 
mine the temperamental characteristics of children, 
and of these environment is perhaps the most impor- 
tant factor. Many a child with a faulty heredity or 
distinctly nervous predisposition, has developed into 
a normal life through the influence of a favorable en- 
vironment. Environment has much to do in deciding 
the character and nervous stability of the child. It 
acts every hour of the day, tending to form the habits, 
lines of action, and modes of thought. ''Parents con- 
trol the bodies and minds, hearts and souls of their 
children, not only through hereditary traits handed 
down from their ancestors, but also by what they 
themselves do a(nd think. Example ^and imitation 
guide the child in thought and action. "^ 

A bad school environment is capable of doing much 
harm to any child, but the best of school environments 
can do little to offset the constant and pernicious in- 
fluence of an unwisely conducted home. To a very 
large extent character is formed in a child during his 
first five or six years of life, so that at the time he 
ordinarily begins school his nervous organization and 

'Development of the Child, (Oppenheim). 



Nervous Disorders of Children 91 

therefore his habits are already pretty firmly estab- 
lished. It is too much to ask of the school that it 
re-educate a child whose first five or six years of life 
have run in wrong channels, or that it correct in a few 
hours each day the influence of the daily faulty habits 
of the home. 

Teachers very soon learn to judge pretty accurately 
of the character of parents by the conduct of their 




A School Providiug Sheltered Passag-es for Play in Stormy 
Weather. Architectural Beauty anil Utility Combined. 
Kasily Adapted to Out-door Lessons. 

children. It is a pity that some of the demerits 
charged to children in the schools cannot be trans- 



92 The Health Index of Chh.dren 

ferred to the parents in the homes. If a child is to 
succeed at school his pleasures and ainiiseiuents at 
home must be simple and wholesome. He cannot with 
impunity be forced or permitted to enter into the social 
dissipations of adults. The child at home must have 
regular hours of eating, sleeping, playing; his discip- 
line must be even and just. "Training should be sys- 
tematic and constant. It is a mistake to permit some- 
thing today and forbid it tomorrow. One should not 
be strict today and tomorrow break all rules by being 
very lenient. There are few parents who are con- 
sistent about a child's training. Most are guided by 
their own caprice." Parents may be too strict, thus 
stifling all spontaneity in the child, or on the other 
hand too lenient so that the child never acquires any 
degree of self control. Children surrounded day after 
day by a home environment little, or not at all 
adapted to character formation furnish most of the 
"nervous" pupils of our schools. 



CHAPTER VI 



SOME GENERAL DISORDERS OF SCHOOL CHILDREN. 

Aside from such disorders as those of the nose, 
throat, ear, eye, defective teeth, and the usual con- 
tagious diseases, many children are discovered in the 
schools who are suffering from more general physical 
troubles. Of these nutritional disturbances probably 
head the list. Many a pupil has successfully passed 
the regular physical examination in schools because no 
defects of the usual sort looked for have been noted. 
Nevertheless some of these very children are the ones 
who are most in need of careful physical attention. 

The following description of such a child will indi- 
cate a common type seen in most schools. The pupil is 
pale, apathetic, thin, maintains a poor posture and 
often stoops badly. The chest is usually thin and con- 
tracted, and in some cases the lymphatic glands, espec- 
ially those of the neck are enlarged. Nervousness is 
often pronounced. Such an appearance may be ac- 
counted for in a number of waj^s. First, it may mean 
that the individual is suffering from malnutrition due 
to a lack of a proper amount of food, or an improperly 
balanced ration. Second, it may mean that proper 
food is being used in a very improper manner. To the 
latter class belong the children who, because of poor 
teeth or for other reasons, hahit being a prominent one, 



94 The Health Index of Children 

fail to masticate their food tlioroiiglily and con- 
sequently never adequately assimilate it. 

In some instances the condition described results 
from the physical maladjustments accompanying the 
period of puberty. xVt this age (twelve to sixteen 
years) the muscles are often flabby and weak leading to 
stooping, a slouching gait and general awkwardness. 
The heart in some pupils of this class is in a very un- 
stable condition aaid often shows signs of considerable 
enlargement (hypertrophy). When this is present 
there is usually some breathlessness on rather slight 
exertion, a disinclination for exercise or play and a 
rapid and sometimes irregular pulse. In these cases 
the phj'-sician often discovers functional It cart mur- 
murs. Organic disease of the heart is found in perhaps 
one per cent of most school children. It ought always 
to be detected in order that the correct advice may be 
given in regard to exercise and other habits of life. 

Sometimes the type described indicates incipient 
tnhcrciilosis. It is very probable that a test of such 
children by the "tuberculin method," would result in 
many positive reactions, which otherwise would remain 
undiscovered until the disease is well advanced. 

Many children displaying low general vitality con- 
stantly sleep in illy ventilated bed-rooms and drink 
coffee or tea in large amounts. The correction of these 
two physical offenses alone has brought about good 
results in several of my own cases. (See Chapter 
VIII). 

Occasionally the condition is due to extreme nervous- 
ness (the neurotic type of child), with irregular habits 



Some General Disorders op School Children 95 

of life of various sorts. In many it is caused by lack 
of outdoor life and sensible physical exercise. Such 
children never play vigorously and unfortunately are 
not educated in this respect in their school life. The 
l)ublic play grounds, with properly supervised play, 
usually work miracles for children of this type. What- 
ever may be the cause of poor physical development, its 
early recognition is one of the most important duties 
of the teacher, parent, physical director and school 
physician. 

These are the types of children who fall by the way- 
side, who lose grades (the retarded pupils), who become 
discouraged and who consequently often lose self con- 
fidence.i To them the teacher owes her best efforts, 
but unfortunately she often gives them scant attention 
because they are not as ''interesting" as the healthier 
and happier pupils. 

Occasionally the condition described is due to in- 
ternal parasites (worms) and attention to this alone 
often leads to excellent results. Such children sleep 
poorly, grind their teeth in their sleep, and often have 
''night terrors." Usually they are nervous, fretful and 
irritable. 

Evil sexual habits in themselves do not ordinarily 
lead to general physical depletion, general opinion to 
the contrary notwithstanding. Many poorly developed 
children are greatly misjudged in this respect. The 
moral effects of such habits are far worse than the phy- 
sical. The persistent sexual sinner among children is 

^Dr. Luther Gulick is of the opinion that when a child of 
average sensitiveness loses two or more grades, he is usually 
ruined for life educationally. 



96 The Health Index of Children 

usually a neurotic individual, and liis sex habits form 
only one of a long chain of other abnormal habits. It 
rarely does much good to attempt to correct the sex 
evil alone, and success is only obtained when the 
whole daily order of life (mental and physical) is 
changed and is placed upon a healthy, normal basis. 

Diseases of the Bones and Joints. i 
All noticeable lameness, whether sudden or con- 
tinued, may indicate serious joint trouble, or may be 
due to improper shoes. These cases, as well as curv- 
atures of the spine, are indicated by habitual faulty 
l»ostures at the desk or in walking, and should be re- 
ferred for medical inspection. 

Spinal curvature should be suspected when one shoul- 
der is habitually raised or dropped, or when the child 
leans to the side, or shows persistent round shoulders. 
Complaints of persistent "growing pains" or "rheu- 
matism" may be the earliest signs of serious disease of 
the joints. 

Diseased Lymphatic Glandts. 
■ The lymi»h glands in children are frequently diseased 
and enlarged, especially those of the neck. AVhen en- 
larged they are commonly known as "Kernels." The 
fact that these glands act as sentinels in the body hav- 
ing the power to arrest or destroy bacteria which gain 
access to the circulation, makes any involvement of 
them of serious importance. It is only when they are 
quite overwhelmed by great numbers of bacteria that 
these sentinels are themselves broken down by the at- 

'From "Medical Inspection," Mass. Board of Education. 



Some General Diseases of School Children 97 

tack of a bacterial enemy. Enlarged Ij'mphatic glands 
therefore always indicate a diseased condition (an in- 
fection) Avhicli must not be ignored. Such enlarged 
glands occur in the acute contagious diseases of child- 
ren. They are also very commonly affected when the 
teeth are badly decayed. The very close relation be- 
tween diseased teeth, poor nutrition and enlargement of 
the lymph glands of the neck, is most noticeable in ex- 
amining school children. Among the first 800 school 
children examined in the schools of Berkeley these 
three defects, viz. bad teeth, enlarged glands, and mal- 
nutrition headed the list. 

This condition of the glands is also very commonly 
present with diseased tonsils and adenoids. The extent 
to which the involvement of the glands occurs depends 
upon the severity of the cause, whether from bad teeth, 
diseased tonsils, or other causes, and upon the natural 
resisting j^ower of the individual. In general a child 
with considerable involvement of these glands has low 
powers of resistance, and indeed it may be said that 
this condition is an index of a low physical state. 
Really healthy children do not show any indication of 
enlarged lymph glands. 

When the glands remain enlarged for a considerable 
period of time one must always consider the possibility 
of a tuberculous condition. Where this is present the 
glands are at first hard and elastic. Later they become 
tender and painful and the skin over and around them 
is red. At last the gland softens and breaks down with 
considerable discharge. 

"Certain observers claim, and advance strong testi- 



98 The Health Index of Children 

mouy to prove, that Avlien enlarged glands in children 
persist and finally lung tuberculosis occurs, the infec- 
tion is conveyed from the glands to the lungs. Seventy 
or eighty per cent of enlarged cervical glands may be 
said to be tuberculous." 



CHAPTER VII. 



DEFECTS OF THE FEET.l 

In a general way the public is now awakening to 
the importance of proper shoeing, and the medical 
profession is being made aware of the real signifi- 
cance of defective feet. It has been shown that while 
some feet present symptoms which point directly to 
flat foot, other defective feet may have no local mani- 
festations; instead they produce remote symptoms 
which are usually associated with other and grave 
disorders. For example, defective feet which did not 
ache nor tire easily nor swell, nor in any way attract 
attention to themselves have been shown to be the 
cause of pain in the knees, in the thighs, in the hip- 
joints, of a whole category of backaches and a painful 
affection of the end of the spine. Some of these (no- 
tably the backaches) are symptoms of other disorders 
which when present, may demand operations. How 
important it is then that in observing these symptoms 
the possibility of defective feet as an indirect cause 
should be borne in mind. Because of the gravity of 
the results should such a condition be overlooked or 
mistaken, this subject cannot too often be given pub- 
licity. Particularly is this so since in the vast ma- 

^For most of the material in this Chapter the author is in- 
debted to Dr. Jas T. Watkins, orthopedic surgeon to the San 
Francisco Hospital and Polyclinic. 



100 The Health Ixdex of Children 

jority of instances defective feet are not congenital 
bnt acquired, and therefore preventable. It is be- 
lieved that the following discussion will throw light 
upon the cause of this condition and indicate how it 
may be prevented. 

In studying the human foot it should be regarded as 
a mechanical contrivance especially devised for weight 
bearing and progression in an upright individual in 
somewhat unstable equilibrium. 

Not only are the feet of individuals unlike, but traces 
of distinct racial t^'pes may be noted ; the negroid, flat 
and flexible; the Semetic, with the flat expanded fore- 
foot of desert dwellers; and the short coupled, rela- 
tively high-arched foot of the Caucasian. 

Among American school children are many whose 
feet, because of their ancestry, show a disposition to 
follow one or the other of these types. It is a matter 
of comment, though as yet unsupported by statistics, 
that a relatively large proportion of children of the 
second group suft'er from defective feet which present 
symptoms — such as pain, weariness, stiffness, or swell- 
ing of the ankles. 

To comprehend the factors to which are principally 
due the almost universally defective feet of school 
children, some slight understanding of anatomy and 
physiology of normal feet is essential. By normal 
feet are meant feet of children which have not been 
distorted nor cramped by wearing defective shoes. 

As mechanical appliances of a well recognized type, 
it should be appreciated in what parts of the feet cer- 
tain actions take place and what structures partici- 



Defects op the Feet, 101 

pate in the performing of these actions. Once this is 
done the ph^^sical environment which is essential to 
the complete performance of a foot's function will be 
appreciated. That is, the several features wiill be 
recognized which must be incorporated in a shoe if 
the latter is not to prove harmful. A comparison, 
feature by feature, of such a shoe with the kind of foot 
wear to which children are habituated from infancy 
will, it is believed, throw light upon the most patent 
cause of defective feet. To such a discussion a his- 
tory of footgear, though interesting, is not essential. 
Suffice it that man would seem to have shown a dis- 
position to decorate his feet and to modify his foot- 
gear to the prejudice of the former's usefulness as soon 
as he found that the unencumbered use of them was 
not indispensable to success in the struggle for exist- 
ence. 

Evidence in support of the view that physical de- 
fects acquired after birth are as a rule not hereditary 
is seen in the fact that despite the distortions to which 
its parents' feet have been subjected the average baby's 
feet are normal at birth. 

Viewing such a foot as a whole it will be seen to 
represent in general a longitudinal arch, high and un- 
stable at the inner side, Ioav and well braced at the 
outer side; and a traverse arch, which in the fore- 
foot exists only when raised, and disappears there 
the moment weight is put upon it. 

The forefoot as it slopes gradually forward, ex- 
pands and is made up of numerous small bones. Its 
function is manifestly that of balancer and shock 



102 The Health Index of Children 

absorber. On the other hand the back part of the 
foot is made up of massive bones, few in number, 
which descend steeply. This part is manifestly adapt- 
ed to bearing weight. 

The comfort experienced by many shoe- wearing wo- 
men when they adopt so-called high French heels is 
due to the fact that part of the muscular effort neces- 
sary to raise the heel from the floor is dispensed with 
and that the heel of the shoe is so devised as to bring 
it more directly beneath the arch of the foot, thereby 
diminishing the strain put upon the ligaments which 
hold the several bones of the foot together. 

Up and down motions of the foot on the leg take 
place in the joint formed by the leg bones with the 
ankle bone. The range of motion in this joint varies 
with peoples and individuals. For example, it has 
been noted that dwellers in the Tyrol and Swiss Alps, 
who wear half shoes and stockings which do not in 
any way impede the motions of this joint, show very 
remarkable joint motion. Again the feet of young 
children show a much greater range of motion in this 
joint than the feet of adults. The conclusion is, there- 
fore, inevitable that the relatively limited up and down 
motions in the ankle joints of the latter are to be at- 
tributed to the restrictions imposed by the ''uppers'' 
of high shoes upon growing and adult feet. 

It will be recalled that during fast walking or run- 
ning, toeing inward is marked and involuntary. In- 
deed it is not possible to walk fast nor run for more 
than a moment without toeing in. This is then the 
attitude of muscular strength and is known as adduc- 
tion. 



Defects op the Feet 103 

If the reader will place one hand palm downward 
upon the table and then without moving the base of 
the palm, crowd tlie fingers as far inward as possible 
•with the other hand, it will be noted that the hand 
which was flat has become arched with the highest 
part of the arch at its inner border, and that the at- 
titude assumed by the fingers is analogous to that 
assumed by the forefoot in turning in. This position 
is seen to shorten the foot and to raise the arch and 
keep it raised. Conversely turning out (the attitude 
of rest) lengthens the foot and lowers the arch. The 
objection to walking with the feet turned out in the 
usual way is thus seen. 

In a properly constructed shoe for a normal foot the 
heel should be broad and low; instead of tapering to a 
point it should remain unchanged or even be slightly 
flanged, thereby increasing the firmness of its tread. 
The shoe should grasp the wearer's heel firmly. The 
shank should be flexible and very short. If the narrow 
shank is long it will bind the foot and prevent the side 
to side motions essential to turning the foot inward. 
The sole should have a straight inner edge and permit 
of the foot's assuming the in-turned or adducted posi- 
tion. In this position a line drawn through the mid- 
dle of the heel will pass to the outer side of the little 
toe. It should have very little "spring" or rocker, 
because this, like a high heel, causes the toes to 
be bent upward. It should be flat from side to 
side and not convex downward as is customary 
in most factory-made shoes. The "upper" should 
be deeper and more roomy at the inner side over 



104 The Health Index of Children 

the high inner arch than at the outer side. Half shoes 
(low shoes) are preferable to shoes with high uppers, 
because the latter restrict the up and down motions, 
of the foot. 

Finally, because feet vary as much as other physi- 
cal characteristics, much care must be taken in select- 
ing that combination of features which are peculiar to 
the individual. Whenever it is possible shoes should 
be made over individual lasts. 

Resume on Fiat-Foot. 1 
The particular defect of the feet known as "tlat-foot" 
is the one of most interest to those whose business it 
is to observe school children. It results from a dis- 
proportion between the strength of the foot and the 
weight it has to bear. Excessive strains, general mus- 
cular weakness, or any condition which weakens the 
foot has a tendency to produce fiat-foot. One of the 
most important factors among children is, perhaps, 
the use of impro})er foot-wear. Most shoes force the 
foot outward and in this position the weight from 
above has a tendency to break down the arch. The 
symptoms of most cases of flat-foot start at or about 
the time of puberty and one of the earliest of 
these is cramps in the calves of the legs. Later 
there is loss of the arch and of the concavity on 
the inner side of the foot. It is very important 
to remember that before much loss of the arch has 
occurred there may be a great deal of pain in 
the calf muscles, in the foot itself, and in the back. 

^The Resume on Plat-foot is largely taken from an article by 
Dr. Edward H. Ochsner of Chicago. 



Defects op the Feet 105 

The foot finally loses a good deal of its range of motion, 
especially the ability to turn inwards. The outward 
turn of the foot becomes prominent, and the ankles 
have a tendency to bend inwards. It is most impor- 
tant to teach children with flat-foot to walk properly. 
To this end they must learn to walk with the feet 
nearly parallel. Children with flat-foot or broken 
arch should receive treatment as early as possible in 
order to prevent serious results. Such treatment can 
ordinarily be given only by orthopedic surgeons who 
have made a specialty of physical defects of this 
character. 



CHArTER VIII. 



POSTURE.l 

Posture exerts a far greater iiilliieiice upon health 
tlian is ordinarily recognized. We commonly value 
it for its aesthetic effect, but this is in fact of relatively 
little importance as compared with its influence upon 
health. Nor must we forget the effect of posture upon 
character. A well poised body gives to others the im- 
pression of a Avell balanced mind, Avhile the constant 
habit of good carriage reacts to the advantage of the 
individual himself. To a great extent we can he what 
icc act. We can, says Dr. Luther Gulick, assume the 
bodily positions and movements and manners and tones 
of voice that belong to the emotional state we desire. 
"Our muscles can be made to express the positive, the 
constructive, the joyful attitude * * * * ^ye be- 
come the thing we act; and if we always act the best 
thing that we have within our power, we are on the 
road to actually becoming that thing."^ 

In the schools of Germany and some other European 
countries the cultivation of a good posture is con- 
sidered a very essential part of a child's education, 

'Without the aid of Dr. Joel E. Goldthwait's paper on "The 
Relation of Posture to Human Efficiency and the Influence of 
Poise upon the Support and Function of tlie Viscera," this 
chapter could not have been satisfactorily presented by the 
writer. Dr. Goldthwait's paper was read at a meeting of the 
Boston Medical Library in 1908. 

="Mind and Work," Dr. Luther H. Gulick. 



Posture 107 

For this reason few German students are seen who do 
not carry themselves well. In this country it is very 
different. The cultivation of a fine carriage is con- 
sidered a luxury, an accomplishment, but not an es- 
sential factor in education. The other day I watched 
the children of a large school assemble in the halls pre- 
paratory to marching out for recess. In the long lines 
hardly a single child assumed an easy, graceful, health- 
ful posture. Some stood on the outer side of one foot 
(one indication, by the way, of a weak arch), others 
stood with heads forward and shoulders stooped ; some 
stood with abdomen forward and shoulders back; some 
with one shoulder much lower than the other (some- 
times an indication of spinal curvature) ; they slouched 
and moved about restlessly in many uncouth ways. 
It occurred to me then that these children were not 
only lop-sided in bodies but were perhaps developing 
lop-sided minds as Avell. 

We are largely what we act, and a slovenly mind is 
apt to go with a slovenly body. One rarely sees a suc- 
cessful business or professional man of very slovenly 
posture. The orderly habit of mind which brings suc- 
cess is usually associated with an orderly habit of body. 
Dr Gulick gives us one of the secrets of such success, 
a secret so simi)le that he who runs may read. "If 
you are walking along the street and wake up to the 
fact that you are carrying yourself poorly, take the 
mental attitude of standing straight, as well as the 
physical one. Look at the men you meet and imagine 
that each one of them owes you a dollar. Put even a 
suggestion of arrogance into your position. Hold your 



108 The Health Index of Children 




Greek Statue of the Sixth Century Sho^viii^- a Perfect 
Staudiug- Posture. 

liead well back; this will not only give the impression 
to others that you possess the power that you want, 
but it will actualh' tend to bring the power to you. 



Posture 109 

Flat chest, flabby muscles, jelly-like abdomen do not 
make for what we call a strong personality. Keep the 
neck against the collar." 

Now children cannot acquire this bodily habit of 
success too early. To be of much use it must become 
instinctive, automatic. The muscles of the child must 
do the right thing at the right time without his having 
to think about it. But muscles must be taught and 
taught early, if such useful automatic action is to ever 
be successfully acquired, for after all education as a 
whole depends for its success upon learning how to do 
most things Avithout having to think. The thinking 
faculty must largely be reserved for purposes of co- 
ordination; it should be spared the petty details of 
purely mechanical functions. 

But even more important than the mental effects of 
posture are the purely physical effects. No one has 
more thoroughly or beautifully explained this than 
Dr. Joel E. Goldthwait, of Harvard University. In 
speaking of the collection of casts from Greece in the 
period of 500-600 B. C. in the Museum of Fine Arts in 
Boston, Dr. Goldthwait says : "There is not a single 
cast or reproduction that did not show the body so 
poised that the greatest eflSciency of the organism 
would be possible." Of one male figure in particular 
he says : "The head is erect and in such balance that 
all of the muscles must be in easy contraction, making- 
possible any movement, forward, backward, sidewise 
or with any combination with the greatest ease and 
with the least possible waste of energy. The chest is 
high, allowing the fullest freedom of action of the 



110 



The Health Index of Cihldhen 



thoracic organs. The shoulders are erect, in which 
position all the muscles are in eas^- contraction, read}' 
for immediate function with the least effort. The 
trunk is so balanced that no group of muscles or part is 




St. Gnudrii's StJitue of liiiieolii IIIiistratiuK- Posture 

strained, but action with the minimum of waste is 
possible, Avliile the visceral ( internal organs of abdo- 
men), supi)ort and function is maintained with the 
Jeast effort. So also, of the legs, there is no strain, 



Posture 111 

but every part is ready for full duty with the least 
waste in either time or energy. The greatest amount 
of general fitness is suggested by the figure, and this 
applies not only to that which is physical, but to the 
spirit or the purpose of the individual. In every part, 
the body, the mind and spirit, the figure suggests readi- 
ness and efficiency * * * * * * * in modern 
times it is not difficult to find equally satisfactory 
types. Nothing can be finer than the St. Gauden's 
figure of Lincoln, which is quite remarkable in that 
even though the figure is depicted in repose, with one 
knee relaxed, the trunk is perfectly erect so that the 
poise of the head is free from strain and the visceral 
function, or support can in no way be disturbed." 

The evil effect of incorrect posture upon the internal 
organs are rather easily explained. In the inclination 
of the body forward or the drooping position, which 
one is apt to assume when fatigued, the breast bone is 
depressed at the upper end. This results in decreasing 
the space in the chest from before backwards, and so 
interferes with the free action of the lungs and some- 
times of the heart as well. In this drooping posture 
there is considerable "increase in the downward in- 
clination of the ribs." This results in a flattening of 
the upper part of the chest under the collar bones at 
the sides and consequently in a restriction of lung 
space at this place. Tuberculosis frequently begins 
at just this point. The organs of the abdomen are 
affected by the drooping or fatigue posture even more 
than those of the chest. In general the effect is to 
shorten the abdominal cavity and crowd the contents 



112 The Health Index of Children 

downward. This often results in serious disorders 
either of the abdominal organs or the organs within 
ihe pelvis. The latter condition explains many of the 
disturbances from which women especially are apt to 
suffer. 

Children often assume bad postures in school, es- 
pecially while reading, writing, or resting at their 
desks. To correct this as far as possible, the child's 
feet must reach the floor, the width of the seat must 
be great enough to come rather close to the knees, and 
it must have a slight backward slope. 

The desk must be so arranged that the child may 
/arc it with arms and hands upon it. The desk must 
come as near the pupil as possible without touching 
him. This prevents leaning forward too far. ''If 
this posture is taken, the head will be erect, the arms 
will offer a support, the chest will be easily filled, the 
shoulders will be on a level, the back will be straight, 
and the position can be maintained for some consider- 
able time without fatigue.''^ 

By maintaining correct posture one avoids a very 
considerable part of the struggle for existence which 
confronts those who have carelessly or ignorantly al- 
lowed their bodies to assume faulty postures. Correct 
posture places the individual in the position of great- 
est physical efficiency. This posture is assumed when 
'^the body is held so that it is made as tall as is possible 
without raising onto the toes. In this position the 
head is erect, the shoulders are thrown back so that 
their center is back of the center of gravity, the chest 

^The Physical Nature of the Child, (Rowe). 



Posture 113 

is liigh, the abdomen is flat, and the spinal curves are 
slightly convex backward in the middle part of the 
back and convex forward in the lower part." 

Elaborate systems of gymnastics are neither enjoy- 
able nor desirable for the average child or adult, nor 
are they in the least necessary for the acquisition of a 
correct posture. All that is required either for health- 
ful exercises or learning good posture habits are sim- 
ple exercises jjracticed daily until the muscles easily 
and naturally hold the framework of the body in the 
positions desired. In school the teacher must not 
only know how to teach correct postures, but ought to 
be herself a constant example of what she wishes to 
inculcate in the minds of her pupils, for no amount of 
teaching however good will ever offset a bad example. 



114 The Health Index of Children 




PART II. 

THE CHILD AND HIS ENVIRONMENT. 



CHAPTER IX. 



FOODS FOR CHILDREN. 1 

In considering- the question of how best to feed 
school children, it must not be forgotten that the period 
of school life extends over a number of years, and that 
in the school house we invariably find children of dif- 
ferent stages of growth and development, and children 
with very widely different needs. It Avould be impos- 
sible for any directions however lengthy, to properly or 
adequately cover the requirements of all children, even 
at the same stage of their lives, Avith their widely vary- 
ing tastes and idiosynocrasies, and their special consti- 
tutional tendencies. No diet list however carefully 
chosen could be used with good results for all children 
of any one age — much less for children of all ages. 

The only hope of a proper solution to this many- 
sided problem, lies in creating in the minds of those 
people who have the catering in charge, an intelligent 
understanding of the uses of the various foods and 
trusting the rest to their discrimination. Many rules of 
dietetics are only of service when applied by the person 
who has had experience with the particular child in 
question, and possesses a thorough understanding of its 
special needs. Only wide general principles are univer- 
sally applicable. 

The scientific principles which underlie the proper 

'Prepared for this book by Mrs. Dr. Jaffa. 



Foods for Children 117 

selection of foods are few and easily understood. 
Chemical analysis has shown us that all foods, no mat- 
ter how simple or how complex they may appear, con- 
tain only four classes of materials. Each class has 
many subdivisions containing an infinite variety of 
chemical compounds. But nothing has been found that 
cannot be classified under these four heads. Two of 
these are mineral matter and water, which are not 
necessary to consider in our present discussion. That 
leaves us only two main classes of nutrients to under- 
stand and to deal with ; the nitrogenous group and the 
non-nitrogenous. 

The question is naturally asked, "Of what use is this 
classification? In what way does it help?" The ans- 
wer is at once plain when we consider that these two 
classes have entirely distinct and separate offices to 
perform in the body. The protein or nitrogenous 
group builds tissues; the bones, muscles, nerves, in- 
ternal organs, etc. It supplies material both for the 
building if new tissues, as in growth, and for the repair 
of the old. The non-nitrogenous group furnishes heat 
to keep the body warm and energy or power with which 
to perform our work. This material may be stored up 
in the body for future use in the form of fat, but can 
never be used to build real or deep tissues. Fat in the 
body is like coal in the basement, ready to be converted 
into heat and energy. Our need of it after we have 
accumulated enough fat to round out our frames is in 
direct proportion to the weather and to the amount of 
energy we expend in both voluntary and involuntary 
functions. The little girl who sits in a warm room and 



118 The Health Index of Children 

reads and sews, does not need as much as her brother 
wlio phiys ball in the cold winter air. 

That brother is the best example of a healtliy crea- 
ture in need of plenty of nourishing food, that we could 
well find — especially if he is in his teens. There, is 
every kind of a call for food that could be found under 
normal conditions. AVho else in the family is growing 
so quickly, who else lengthening out and widening every 
bone and tissue of the body? The baby of the family 
may be doing that, but she is not studying or exercising, 
neither is she under nerve strain. The father may be 
using his brain in his work and may be under nerve 
strain, but he is not growing and may not be exercising 
overly much. Rarely indeed do we find a human crea- 
ture, whose demands for food materials are so many 
and so urgent as those of the boy in his teens. 

If the problems involved in the proper feeding of a 
growing boy be solved first, the results may be modified 
for other children, up and down the line, according to 
their ages and conditions, and their individual needs. 
We have come to know a great deal about the food for 
the first period of rapid growth, that of infancy, since 
the chemical analysis of mothers' milk has furnished 
us with a perfect model upon which to base our selec- 
tion of substitutes when the natural food fails us. But 
the second period that comes early in the *'teens" is not 
3'et so generally' understood. 

During these 3'ears of adolescence, when Nature is 
making every efl'ort to develop and round out the per- 
fect individual, she needs all the help we can give her. 
She can not build if we do not supply her with material, 



Foods for Children 119 

but she can, and often does, build one part at the ex- 
pense of another. It is a common thing to hear a 
mother say, with reference to a child, that he "outgrew 
his strength." Translated, that expression means that 
the child did not get, or was not able to use, sufficient 
food material to supply all the needs of the entire 
organism. 

It is the second and last chance that Nature has, to 
remedy defects in the constitution, and she makes a 
desperate effort to accomplish it. The results of im- 
proper feeding at this time can not be easily remedied. 
It is often a case of "now or never," and the work that 
is not done in this second formative period of life may 
not be done at all. Weak spots in the building will 
alwa^^s remain weak spots, and Ave should not run any 
risks at this time. Many of the nervous symptoms 
usually observed during the period of adolescence are 
not necessary or normal. The nerves suffer from in- 
sufficient and improper nourishment, as well as from 
other wrong and unhygienic conditions during the 
early "teens." (See Chapter V). 

When the importance of proper nutrition is once 
fully realized, the first question asked is, "How can we 
supply it — what kind of food does the child need?" 
The answer is very plain. He needs All Kinds, and in 
sufficient quantities. He should be fed not only from 
the different classes of foods, but from the various sub- 
classes, as well. Fortunately for us, most foods con- 
tain some nutrients from each. When we classify 
foods we place them according to the largest amount 
or importance of some ingredient that they contain, but 



120 The Health Index of Children 

that does not mean that they do not contain any other. 
The following table illustrates this jioiut. Some of 
our common foods are placed under the class to which 
they belong, while in parenthesis are indicated what 
important nutrients of the other class they contain. 
Verv small amounts are not so indicated : 



Foods for Children 121 



> ^ 

So 





trt 








+-> 

be 



iH 


(TQ 


-i-j 


O 




(1) 


O 
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■*-> 

o 

o 




fe 


m 


o 


> 





rH S^ CO -^ LO 



CO 




,-^ 


^ 








































Q 




3 


o3 


















;I^ 






CO 
















O 
O 
L. 

U. 


a 

3 
O 




m 


bD 














a 

3 
O 

L. 

C5 


.5 
'i-i 




to 

03 


03 
bfl 

to 


to' 




to 

*3 

fa 










O 

z 
o „• 

K- 
< 

o 
u. 

CO 
CO 

< 


O 
w 

3 
O 
E 
(U 
O) 

s 

"z 


'3 
m 

o 



a> :;3 


03 

M 

bJ3 

be 


<p 
ai 


03 


tJ o 
to +J 


S' 

o 

02 

CO 

o3 

m 


03 „• 
to " 

m 
03 
CD 

Pm 


(0 

3 
O 

c 

V 

en 
o 

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c 
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H 
c 


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03 

T3 


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01 

a 
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CO 


01 
01 




03 
bi) 








o 


















Z 


ffi 






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pi 






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rH 


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00 


oi 






o 




g 


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o 
u 
ft 


fl 


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o 


























X2 

o 




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p 




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O 
o 

o 
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bD 




























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to 
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'3 

o 

y 


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4J 






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to 
to 

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rlS 


el 


Pi 


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13 
































< 


03 


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o 


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01 


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0> 


03 






























02 


o 

to 
"cS 

M 


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CO 


o 

CO 

"S 
o 


o 

CO 

13 


to 

01 

o 

-l-J 


Ol 

o 

"cd 
-i-j 
o 

Ph 
0> 


03 
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bB 
01 
> 

PI 
05 


o 
o 

O 
CO 

13 

to 
































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Ol 

O 


o3 


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Pi 


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u 

fa 
































rH 


im' 


CO 


■^ 


LO 


(6 


t>^ 


00 



122 The Health Index op Ciiildken 

It is important also that we should not ignore the 
subdivisions. While the sugars, starches, and fats 
belong in one large class, and apparently perform the 
same office, they vary greatly in other ways. Starch 
must first be converted into sugar, in the digestive 
tract, before it is absorbed and used. Therefore, it 
would be much more difficult for the body to obtain all 
of its carbohydrate from starchy food, rather than 
from starch and sugar both. Again, fat is worth two 
and one-fourth times as much as either starch or sugar 
for producing energy. The Esquimaux and Lap- 
landers realize this when they eat their tallow and 
blubber during the long and severe Arctic winters. 

The boy's instincts, too, will lead him to choose the 
all-round diet that he needs, provided he has an oppor- 
tunity for selection. He can not choose what is not 
there, and his instinct will rarely be strong enough to 
cause him to demand what he does not see. To limit 
his choice to a few articles is to tempt him to over use 
the one that appeals to him the most. To regulate his 
diet according to the taste or fads of the grown-ups is 
to hamper him most cruelly. It is not necessary to 
weigh or measure or count it out. It is only necessary 
to see that he is provided with some food materials 
from each important group. 

Protein, or nitrogenous food, he needs, of course, in 
large quantities, to furnish the huilding material with 
which Nature is to develop the frame of the child into 
that of the man. It is not well for him to get it all 
from meat — that puts too much strain on the organs 
of elimination. The "meat substitutes" should be kept 



Foods for Children 123 

in mind and provided for the non -meat meals. He 
should be given milk and eggs or nuts, cheese, beans, 
lentils, etc., and he will not crave meat as inordinately 
as most bojs do. His need of building material will 
thus be partially satisfied but it should always be re- 
membered that he requires more protein than an adult 
until he has his full growth. 

The non-nitrogenous foods are in great demand as 
well, to furnish the body heat and the energy for all his 
work and his "sports," and to round out his frame. 
But he should not be expected or allowed to get all he 
needs of it from starchy foods. They are very bulky 
and would prove an unnecessary strain on the organs 
of digestion. Do not be afraid of sugar as part of a 
meal. Candy is an excellent dessert for active grow- 
ing children — and nut candy — properly chewed is es- 
pecially nutritious. Remember that Mother''s milk 
contains five per cent of sugar and is the ideal food for 
the growing body of the infant. It contains protein, 
sugar and fat but no starch. 

Fat is a most important element in the dietary. 
While its office in the body is the same as that of the 
other non-nitrogenous foods, its digestion is different, 
and it is worth more than twice as much in furnishing 
heat and energy. No child should be allowed to go 
without fat simply because meat fat or butter are dis- 
tasteful or do not agree. One kind after tlie other 
should be tried — cream, ham or bacon fat, nut oils, 
vegetable or fish oils — until the right one is found. 
When fat is not tolerated with one kind of food, it 
often will be tolerated in a different combination. 



124 The Health Index op Chh.dren 

Some concentrated nonrishnient should be used at 
each meal in connection with the more bulky foods, so 
that the proper amount may be taken without crowd- 
ing the digestive apparatus. The sugars and fats are 
the most concentrated foods — ^and meat, cheese, eggs, 
etc., next on the list. This means that there is less 
water and waste material in them. 

At first glance it may appear that no real directions 
have been given for the dietary of a growing child. 
''Feed him everything. He eats everything now." But 
perhaps a second and more careful glance will disclose 
errors. True, there is no one great radical change 
advocated; but it is the accumulation of all the little 
things that makes the real difference. Nature works 
slowly. In order to help her we, too, must work slowly 
and patiently with carefully thought-out meals, con- 
scientiously persisted in for years, if we expect to see 
results. Some apparently slight change made in each 
meal three times a day for 3G5 days in the year would 
make a great difference in the end. 

Suppose for instance, it were decided to add "grow- 
ing material to the dinner'' other than the meat. Sup- 
pose the meat soup were replaced occasionally by a 
bean or pea soup or by one of the various milk soups ; 
and that on other days the potatoes were replaced by 
rice or macaroni and peas used more frequently than 
other vegetables; and that on others, the pie were re- 
placed by custard or soft home made candy — would not 
that alona make considerable difference at the end of 
the year? 

And if for breakfast, oatmeal were used instead of 



Foods for Children 125 

wheat or wheat foods — breakfast cheese for those who 
do not eat meat or eggs, milk or cocoa instead of 
colfee — milk toast instead of dry toast, etc., would not 
the sum total of the year's breakfasts count? 

The meal that usually requires the most radical re- 
construction is the lunch. Between the children that 
rush home and swallow a hasty bite of unsuitable 
material and hasten back for fear of being late, or else 
to play with the other children, and those who carry a 
cold lunch composed of food that would not furnish 
very much nourishment, even if it were not diflflcult to 
digest — there remain probably, only a small percentage 
of children whose lunches are suited to their needs. 
This is a great drawback in many cases, for it is often 
the one meal where individual requirements can be 
most easily attended to. To slight one meal out of 
three is to slight a very large portion of the child's 
opportunities for nourishment. 

The lunch can never be considered alone. It must of 
necessity depend largely upon what is given for the 
other meals of the day. It is really not a difficult task 
to make one meal complimentary to the others when 
the habit of mind is once established. Having acquired 
a permanent mental picture of the food groups, and 
having the special requirements of the child, it becomes 
an easy matter to arrange a lunch of nourishing ma- 
terials not supplied by the other meals. 

Does he eat heartily of meat at night and perhaps 
has some for breakfast? The lunch should contain 
"non-meat protein." Does he prefer the vegetables and 
dessert at dinner? Give him meat at noon. Do the 



126 Tub Health Index of Children 

other members of the family object to oil or fat? See 
that the growing boy gets peanut butter or mayonnaise 
sandwiches, etc., for his lunch. Is his breakfast light? 
His lunch should then be very hearty. Is he tired at 
dinner time, and sleepy? His most nourishing meal 
should be at noon. Does he refuse eggs for breakfast? 
He may relish and digest them Avell for lunch, and thus 
it goes. It would be impossible to cover the ground of 
the various elements involved in the decision. 

In general, the lunch, as well as the other meals, 
should be as simple as possible in order to supply the 
required nourishment. The work of handling the quan- 
tity and kind of food, needed to build up the physical 
frame, and keep the organism in good running order, 
is (juite enough strain on the digestive organs, without 
hampering them with unnecessarily complicated or 
difhcult dishes. As a rule, made dishes, fried food, 
"warmed overs," smoked and salted meats, thickened 
gravies, etc., should not often be given even to the 
healthy child, and uerer to one whose digestion is weak. 
Food that is difficult of digestion may often be 
handled jierfectly on occasions, Avhen frequent repeti- 
tions would cause disastrous results. It must never 
be forgotten, in this connection, that "what is one 
nmn's meat is another man's poison," and careful ob- 
servation is the only sure guide. 

The main points to keep in mind may be summarized 
as follows: 

Be persistent in using foods from each group. 

Be sure to use plenty of "growing material"" without 
going to an extreme with meat. 



Foods for Children 127 

In iisiug meat subKstitutes remember: 

(a). — That milk is tlie most valuable one to use if it 
agrees, and that skim milk is just as rich in growing 
materials as whole milk. 

(b). — That eggs come next in order. 

(c). — That nuts must be ground or very icell chewed 
in order to be properly digested and assimilated. 

(d).— That soup meat has all the growing material 
left in it, and none of the deleterious elements (uric 
acid-forming materials, etc., that are in the soup), and 
is a cheap and excellent food, and can be made into 
appetizing dishes for breakfast or lunch. 

(e). — That oatmeal, macaroni, rice and gluten flour 
have more growing material than potatoes or wiiite 
flour. 

f). — That in using nuts, cheese and beans, the ques- 
tion of individual digestion must dictate the choice. 

Do not forget that in pushing nourishment, some 
concentrated foods should always be used witli the 
more bulky ones. 

Fruits and vegetables have a hygienic and a medic- 
inal value, but after this purpose is well served, they 
are expensive food materials. 

In comparing the prices of the different foods, we 
should consider the amount of nourishment they con 
tain as well as the price per pound. 

Eating between meals should only be allowed where 
it is prompted by hunger and not by a desire for 
goodies. Only easily digested foods as crackers and 
fruit, etc., should be given at such times. 

The nourishment should be fairly well distributed 



128 The Health Index of Children 

among the three meals, and not crowded mainly into 
the dinner. 

The weekly dietary shonld contain considerable va- 
riety, but the single meal, not too great a mixture. 

Study the effects of combinations before discarding 
any food from the diet list. 

Never crowd nourishment nor risk indigestible food 
on occasions of excitement or fatigue. 

After indulgence in an unusually heavy or taxing 
meal see that the next one is uuusuall}' simple. 

When protein is added to the dinner for the sake of 
the children, the '"growu-ups" may eat less of the meat. 
The necessity for careful mastication is a lesson that 
children can not be taught too early. 

When the ''what's, the why's and the wherefore's" of 
feeding the growing boy in his teens, are well under- 
stood, it becomes an easy matter to cut down and mod- 
ify his dietary to suit the cases of the younger or the 
older children, the fatter or the leaner, the more active 
or more sluggish, the thriving or the poorly nourished. 
It is only necessary to keep in mind what the foods do 
in the body, and the special needs of an}' nornml child 
may be easily met. Those who are suffering from 
weakness or disease should be under the care and 
direction of a physician. 



CHAPTER X. 



HEALTH AT HOME IN RELATION TO SCHOOL HEALTH. 

The school is often criticized for results which really 
originate in the home. It has become a common habit 
now-a-days to find fault with our school system in 
nearly every particular. 

Some of this present day criticism is just, and is 
therefore accomplishing much good, for our schools are 
rather keen to give heed to fair complaints. But much 
of the complaint is mereh^ destructive in nature and is 
often based upon misconceptions of actual existing con- 
ditions. 

Our present school methods undoubtedly do produce 
many physical defects and contribute to others orig- 
inating elsewhere, but the fault is just as often to be 
found in various abnormal home conditions, and in 
ignorant or careless physical neglect. School health 
and home health are interdependent, and an oversight 
of this plain fact often leads to many errors. 

1. Not long ago I noticed a little girl of twelve years 
in one of the best Berkeley schools who appeared sin- 
gularly nervous and queer. The usual physical exam- 
ination revealed nothing of particular importance. 
Eyes, ears, nose, throat, teeth, heart, lungs, and the 
like, all seemed healthy enough. Yet that the child was 
far from normal in some respects was apparent in her 



130 The Health Index of ('hh,l)I(ex 

general appearance and nervous demeanor. A home 
visit from the school nurse revealed at once the nature 
of the difficulty. 

The mother while by no means indigent considered 
that her circumstances were too straightened to justify 
her in purchasing milk for her child to drink. She 
therefore kept the cott'ee pot constantly on the stove 
and permitted the little girl to help herself as often as 
she wished. The result was that this child was drink- 
ing a pot and a half of strong coffee daily. 

The mother thought that coffee was a food and a 
cheaper one than milk, so she ignorantly made use of it. 
The child's condition in school was thus easily and 
quickly explained. 

A few simple explanations on the part of the school 
nurse soon set this mother right, and one less school 
child was from that moment a victim of the coffee 
habit. 

2. In another school a boy of ten years was observed 
who appeared illy nourished, pale and apathetic. There 
again the physical examination revealed no defects of 
the usual sort, but the nurse's visit to the home ex- 
plained the trouble. The boy slept in a very small 
bed-room opening out of the kitchen. In both the 
bed-room and kitchen the windows were kept care- 
fully and conscientiously closed at night, and during 
the day the air was never Avholesome. A simple lesson 
on the hygiene of ventilation given on the spot by the 
tactful nurse worked wonders. A few weeks of sleep 
in the same room with the windoAvs thrown wide ojjen 
at night jjroduced a very different looking boy. 



Health at. Home in Kelation to School Health 131 

The little girl in the first case was coffee jmisoned — 
the little boy in the second case was air poisoned. 

These instances just related are by no means excep- 
tional, but fair types of many such cases met by care- 
ful physical examiners in the schools. 

Of over 500 children in the Berkeley Schools, in the 
grades from the third to eighth inclusive, it was dis- 
covered that 53 per cent use tea or coffee or both daily, 
and in this respect these schools are not exceptional. 
This habit deserves more serious consideration on the 
part of parents and teachers than is usually given to 
it. Disguise it as one may, this is a mild drug habit 
and while not necessarily of great importance in its 
effects upon healthy adults, it certainly has seriously 
bad effects upon children. It is high time to teach 
temperance in all tilings instead of unduly focussing 
attention almost exclusively^ upon tobacco and alcohol. 

Many school children live in homes of more or less 
constant unstable nervous equilibrium. An irritable 
mother or father can hardly fail to produce an irri- 
table child. 

An irritable child at school rarely makes good pro- 
gress, and is frequently scolded and punished by the 
teacher. The child Avho leaves home for school in a 
state of nervous excitement from any cause must not 
be blaiued for capriciousness, irritability, or misbe- 
havior in the school room. The influence of environ- 
ment is greater than that of heredity. 

TJie daily home environment very largely determines 
the child's conduct in school. Let the tactful teacher 
or nurse investigate the home conditions of her nerv- 



132 The Health Index of Childuex 

oiis, misbehaving children and she will nearly always 
discover the exciting cause of the child's actions. 

Conditions of malnutrition are very frequently ob- 
served in school children. This condition is by no 
means always due to poverty at home. The fact is 
that relatively few families in this country are too 
I)oor to furnish their children with nutritious food 
in pro{)er quantity. The counnon explanation is ig- 
norance of what sort of food the child really requires 
for good health. Children are most often allowed to 
make their own selections of diet. The whim and the 
caprice of the child are too fretiuently encouraged. 
Children and adults can with very few exceptions 
eat Avhat is placed before them when the food is intelli- 
gently selected and well itreparcd. 

3. I re<-ently noticed two children, brother and sis- 
ter who had a singular pallor and appeared jioorly 
nourished. Their work in school was of low grade. A 
visit to the home brought out the interesting inform- 
ation that the breakfast of preference with these child- 
ren consisted of pic, pirllcs and coffer, and this pre- 
ference was not infrecjuently indulged. It was with 
great difficulty that the mother (a fairly intelligent 
Norwegian i was persuaded that no child can thrive 
upon such an atrocious morning meal. 

4. I once found a little boy of eight in the schools 
another city whose sluggish motions, pallor, and ema- 
ciation were apparent to any observer. A few direct 
questions elicited the information that his breakfast 
usuallv consisted of strong cotfee and bread without 



Health at Home in Relation to School Health 133 

buttei-. For limcli lie usually had some bread and 
butter; for supper some soup and bread. His parents 
were Ignorant, shiftless, and poverty stricken. A 
wholesome lunch of good variety was provided for 
this boy and the parents instructed about the necessity 
for a properly balanced ration. The result was that 
the child soon grew strong and healthy in appearance 
and improved greatly in his daily school work. 

5. It is not altogether uncommon to observe cases of 
absolute home neglect among school children. The 
folloAving case will serve as an illustration. A boy 
in a second grade asked his teacher to excuse him 
from the usual physical exercises in school, which she 
I)roraptly did. He said, "it hurts me to do those 
things." Upon examination I discovered a large tuber- 
cular abscess in the groin. This abscess was discharg- 
ing and yet had never been dressed nor had it received 
any kind of attention. It was with difficulty that the 
j)arents were made to understand the seriousness of 
the condition. Proper surgical treatment cured the 
case in a few weeks. 

6. Another boy in the same grade had a peculiar 
walk which the careful teacher had noticed. He was 
very delicate looking and had once fainted on his way 
to school. Investigation demonstrated tliat this child 
was suffering from chronic appendicitis, which the 
parents had evidently neglected. I insisted upon the 
child being removed from school and being placed 
under a physician's care. In two months he returned 
a well and relatively strong boy. 

7. A third boy in this grade breathed so loudly 



134 The Health Index of Children 

through his mouth that all the pupils in the room were 
disturbed. He was apathetic and stupid looking and he 
made no progress whatever in his studies, yet his par- 
ents had not observed much that Avas wrong with him. 
These parents Avere notified that adenoids were present 
and an Operation was advised and done. When I next 
saw him one year later he was scarcely recognizable 
as the same child. His whole appearance had changed, 
he breathed quietly, his facial expression was bright, 
he had improved in physical vigor, and was doing as 
good work as the other children in his grade. 

8. Sometimes the most evident principles of home 
hygiene are violated to the serious detriment of a child. 
My attention was called by a teacher to a boy in a 
fourth grade who was constantly giving her trouble. 
He was sullen, irritable, refractory, quarrelsome, and 
misbehaved generally. His physical appearance was 
extremely bad. Upon examination I found plain evi- 
dences of lung disease. He had a constant cough and 
it was said that there had been some sort of a hem- 
orrhage some time before. 

The school nurse discovered that this was a case 
where the father was tuberculous and that this boy 
had slept in the same uuventilated room Avith his sick 
jtarent. No attention Avas given to a reasonable diet 
in this home and the household Avas in general A'ery 
badly ordered. Against the wishes, and indeed Avith 
the absolute disapproA^al of the parents, the boy was 
taken out of school. Some sensible hygienic instruc- 
tions AA'ere giA'en by the nurse and an out-door life ad- 
vised for the boy. Some months later I saw him on the 



Health at Home in Relation to School Health 135 

street, and to all appearances he Avas well on the road 
to recovery. 

9. The neglect of the practice of dental hygiene is 
the rule rather than the exception among school child- 
ren. For this state of affairs the home is of course pri- 
marily to blame. The plain fact that clean teeth do not 
decoy had not as yet sunk into the inner consciousness 
of most parents, nor do they understand that various 
serious disorders originate in neglected teeth. A par- 
ticularly striking instance of such dental neglect is 
furnished by the case of a boy whom I examined in 
a Pasadena school. He was reported to me because 
of his poor general physical appearance, but the teach- 
er had not noted any trouble with the child's teeth. 

An inspection of the mouth revealed the whole dif- 
ficulty at a glance. The teeth were in a horrible state 
of decay. One tooth in particular was badly ulcer- 
ated, the gum had receded and most of the root on 
the cheek side was exposed to view. Some of the 
tissue was evidently tuberculous. Strange to say, 
the father offered the greatest possible opposition to 
having the teeth properly cared for, believing as 
most parents do that first teeth are meant by nature 
to decay and that it is not worth while to interfere 
with nature's beneficent methods. The older brother 
of this child was at the same time suffering from en- 
larged and discharging tuberculous lymph glands in 
the neck. Both children were miserably nourished, 
nnhapi)y in appearance, and making no progress in 
school. 

After repeated efforts on the part of the school phy- 



13G The Health Index of Chu.duen 

sician and the Principal of the school, the fathei* at last 
consented to have these boys placed under proper treat- 
ment. One year later I met them as I was driv- 
ing one afternoon in the country. Their vigorous 
appearance and exuberant spirits were in such marked 
contrast to that of a year before that at first I did not 
recognize them. They had been visiting an aunt in 
the country, and were now walking home, a distance 
of six miles, and the smaller and formerly less vigor- 
ous boy was pulling the. other one in a wagon ! 

Two boys like these saved from misery and perhaps 
death and made happy and useful, justify, the ex- 
pense of a School Health Department. Yet some ])eo- 
ple still doubt the advisability of health supervision 
of children in the schools! 



CHAPTER XI 



THE HEALTH OF THE TEACHER. 

Ver}^ few schools in this country pay any serious 
attention to ttie health of their teachers. Even in the 
matter of vaccination, although usually required of 
all pupils, teachers are ordinarily exempt. Not only 
is this true of teachers, but few Normal Schools in- 
sist upon any adequate physical examination of their 
students. The result of all this is that some teachers 
are employed who are constant menaces to the pupils 
entrusted to their care. Tuberculosis, although rather 
common, is not the only disease from which teachers 
suffer and which may react seriouslj^ upon their pupils. 
When we consider the amount of time which a child 
spends under the care of a teacher and the intimate 
relations which exist between them, it is evident that 
the teacher is only second in importance to the mother 
herself. Despite these self evident facts the teacher's 
l)hysical condition rarely receives consideration, either 
for her own good or for the good of the child. 

Books on School H,ygiene or on Medical Inspection 
of Schools seldom discuss the subject of the teacher's 
health at all, or if they do, the topic is treated most 
inadequately. 

Of all physical disorders, nervousness in its various 
phases is probably the one of greatest importance 



loS The Health Index of Chh.uken 

among teachei-.s. Public school teaching is of necessity 
(according to our present rather irrational sj'stem) 
a nerve racking occupation, even to those teachers who 
begin work with well balanced nervous organizations. 
AMiat may we expect then of those individuals in the 
teaching profession who never have possessed much 
nervous stability ? 

Nervous Disorders Among Teachers. 

One of the strongest arguments, among many others, 
in favor of a greater proportion of men teachers in 
the upper grades of our public schools is the fact that 
women by nature possess as a rule far less nervous sta- 
bility than men. All of these facts are, however, large- 
ly ignored in the selection of teachers in our schools, 
and we go on complacently placing our sensitive child- 
ren during the most important formative periods of 
their lives, under the care of teachers who may be a con- 
stant daily source of injury to them. The writer remem- 
bers very vividly one of his own teachers in a third 
grade who had so little self control that she was regard- 
ed with the greatest fear by her pupils. The slightest 
childish indiscretion was sufficient to send her into 
fits of uncontrolled anger, during which she would 
grab the unhappy victim (most often the present 
writer) by the scrutf of the neck and whirl him about, 
red in the face and choking, until his feet struck the 
to])s of the desks and the life was nearly shaken out of 
him. This teacher never smiled, she was always sour, 
unhaj)py, despondent, ill-natured. The influence up- 
on sensitive children of a year si)ent under such a 



The Health ob^ the Teacher 139 

termagant cannot be estimated, and the memory of it 
can never be entirely effaced. Later in life this wo- 
man's actions were easily explained to the satisfaction 
of her chief victim. Her mother and one sister became 
violently insane. This teacher possessed an extreme 
neurotic type of character which she had undoubtedly 
inherited, and, was no more fit to deal with young- 
children than are many of the inmates of insane 
asylums. 

Violent uncontrolled tempers and other ill natured 
actions are not the only or chief manifestations of 
nervousness in teachers. Many estimable, good na- 
tured, conscientious individuals possess little sense of 
composure. Sometimes teachers of this type are es- 
pecially gay, vivacious, affectionate, ;dem;onstrative. 
Their very over-indulgence in these estimable qualities 
often unfits them to fulfill their duties properly. Such 
teachers are constantly solicitious for the welfare of 
their charges, they are all "dears and darlings"; they 
are coddled or severely disciplined by turns, and with 
little discrimination. I have seen some women teach- 
ers of this type who had succeeded in disorganizing 
the entire school through such manifestations of nerv- 
ous instability. Repose with them was never practiced 
and therefore repose was an unknown quantity among 
the children in their schools. 

Children in such schools dread the visits of the 
school nurse or physician because they have been told 
over and over again that "the doctor isn't going to 
hurt you," or "the nurse won't carry you away," or 
given similar unwise suggestions which in themselves 



14U The Health Index of Children 

intimidate the child. Such teachers, like some par- 
ents, are likely to threaten certain children with an 
"examination by the doctor, to see why they don't 
behave." Under snch circumstances the child of course 
comes to look upon the doctor as he does upon the 
"Policeman" or other bugaboo, of which some fond 
teachers and parents make constant use, to secure 
easy obedience. 

Teachers, of all people, need to acquire a good sense 
of repose and must learn to administer discipline with 
wisdom and judgment. 

Next in importance to the ill-tempered or over-so- 
licitous types of teachers, come the depressed and mel- 
ancholy types. These individuals rarely bring light 
and joy into the school room. They inspire awe but 
never love; they obtain "discipline" but never obe- 
dience. To this type, teaching is usually a necessary 
evil, and pupils are regarded as unfortunate incidents 
in their daily work for a livelihood. No school room 
should ever be clouded by the presence of such brood- 
ing sfonii centers. Children require a cheerful, happy 
environment, and if they do not secure it their lives 
are always blighted, for they are sensitive little human 
plants reacting to the slightest human frost. 

Then there is the intoisvli/ and ahnormaUy active 
teacher. This type is never at rest. Every common 
duty is performed with a wearisome strenuosity which 
leads the child in time to long for an opportunity to 
just once explode and relieve the tension. 

Finally there are the victims of hah it-spasms of one 
sort or another, which some children so readily and 
skillfully acquire by imitation. 



The Health of the Teacher 141 

The writer i-einembers one such teacher whom he 
had in his extreme youth. She constantly twitched 
and Avrinkled her nose as if she smelled something un- 
pleasant. It was not long before half the little boys 
in the class, with this ever present example before 
them, were going about sniffing the air like young 
colts. One eye-hlinking teacher will sometimes set 
half of the girls and some of the boys to winking their 
eyes furiouslj^, while any other peculiar nervous habits ' 
of the teacher, such as nervous laughing, raising the 
brows, stammering, nail biting, coughing, and the like, 
are soon reproduced with avidity by several of the apt 
pupils. 

All of these types usually represent varying degrees 
of neurasthenia, or an unstable nervous equilibrium, 
which in itself if uncontrolled, ought to debar their 
possessors from the serious responsibility of training 
children. 

Indigestion. 

Next to nervousness, indigestion in its various phases 
is probably the commonest complaint among teachers. 
For this state of affairs there are many reasons, but 
most of them fall into a common group, viz, lack of 
exercise, worry, insufficient mastication, improper prep- 
aration of food. 

There is no better way to keep healthy and happy 
than by learning the importance of careful habits of 
eating. Most of our headaches, "fits of the blues," 
and depressed feelings come from the abuse of food. 
People tvith healthy digestions are rarely sick. 

Unless we take good care of the digestive organs, we 



142 The Health Index of Childuex 

cannot expect to have niucli resistance against disease. 
Tlie digestive organs naturally' secrete juices which 
are antagonistic to many disease germs. Abuse of 
these organs weals:ens their powers of defense. INIauy 
colds are fallen because of disordered digestion. De- 
cayed teeth are more often caused by indigestion and 
bad nutrition tlian by anything else. 

It is no disgrace to be sick when we cannot prevent 
it, but ignorance of how to keep well is rather worse 
than any other sort of ignorance. I have seen many 
teachers of Physiology and Hygiene who as practical 
examples of the observance of the kiAvs they taught, 
were very sad failures. One may be justly proud of 
vigorous health, especially when it is the result of 
careful study and obedience to nature's laws. 

I'robably more sickness is caused by the improper 
use of food than by any other one thing. Most people 
eat too much food. Overeating easily becomes a habit. 
When the stomach is overloaded, digestion is retarded 
and some of the food is sure to fer)ue)it. Gas forms 
and also certain other products of fermentation. The 
gas causes bloating, Avith uncomfortable sensations. 
Sometimes the stonuich pushes up against the heart 
and causes pali)itation. Many persons imagine they 
have heart trouble, when indigestion is really the cause 
of the symptoms. The fermentation products are ab- 
sorbed by the blood and circulate in the body. Some 
of these are poisons. By overindulgence in food, which 
may in itself be harmless, a person may thus poison 
himself, just as if he had swallowed actual poison. 
This is one of the commonest causes of headache. 



The Health of the Teacher 143 

The state of the mind has a great deal to do with 
how our different organs do their work. Pleasant 
company, good cheer, and attractive food all stim- 
ulate the organs of digestion to do their best work. 
Unpleasant surroundings, unattractive food, or worry 
may cause an attack of indigestion. People hardly 
ever suffer from indigestion after a pleasant banquet, 
even when they overeat. But the most frugal meal 
with a bad temper or other unpleasant conditions may 
actually stop the process of digestion. 

Many persons suffer from chronic dj^spepsia simpl}^ 
because they imagine that their food will disagree Avith 
them. ^Vlien the mind is directed into cheerful and 
healthy channels and common sense is used about eat- 
ing habits, dyspepsia usually disappears. Dyspeptics 
generally form the habit of thinking too much about 
themselves and of resorting to -drugs from which they 
appear to expect miracles. 

A healthy person has a good appetite and enjoys 
eating. But such a person does not form unnatural 
food habits. One should not be fussy about food. It 
is easy to get into the habit of thinking that one can- 
not eat this or that particular kind of food, but with 
few exceptions, we can eat any wholesome food. The 
less one worries about his food, the better. 

Fads in regard to food and peculiar diets oughc to 
be studiously avoided. These fads seem to be the par- 
ticular obsessions of teachers. We hear much of fruit 
diets, vegetable diets, nut diets, the no breakfast cure, 
and the like. One needs only to remember that experi- 
ence has proved, and science has demonstrated, that a 



144 The Health Index of Chh.dren 

mixed diet taken three times dailij is best for the aver- 
age man or woman. The diet question is very easily 
and very satisfactorily settled by remembering that 
thoroiigh mastication of all sorts of common sense, well 
prepared food will preclude the danger of over-in- 
dulgence, and if one will thoroughly masticate or 
"Fletcherize" one may forget most other rules of eat- 
ing with irapunit3^ 

Headache. 1 

Headache is a distressing symptom from which many 
teachers suffer, and Avhich materially decreases their 
happiness and usefulness in school. It ought to be 
kept clearly in mind that headache is a symptom, and 
not a disease in itself. 

It has many causes, among Avhich may be mentioned 
the following: eye strain, nervous exhaustion, men- 
strual irregularities, poor nutrition, indigestion, jaun- 
dice, catarrh, rheumatism, neuralgia, and had ventila- 
tion (air ])oisoning. ) Eye strain, consti})atiou, indi- 
gestion, bad ventilation and nervous exhaustion are 
by far the commonest causes of headache. One ought 
always to attempt to discover the cause of a headache 
before trying to treat it. Such causes are usually not 
hard to find, and once known, the treatment is usually 
successful. If the cause is not easily discovered and 
remedied, medical attention is necessary, for headaches 
should never be neglected. 

The common method of resorting to "headache 
powders" and other drugs, Avithout nnu-h thought as to 

'Most of the material on headaches, dyspepsia and colds is 
taken from the author's Health Studies, D. C. Heath Co., Pub- 
lishers. 



The Health op the Teacher 145 

the trouble, cannot be too severely condemned. Most 
headache powders advertised as cures contain coal-tar 
products, such as acetanilid, which if used without the 
advice of a physician, are likely to injure the heart 
and do much other harm. Such remedies never re- 
move the cause, thej merely afford temporary relief 
and deceive the senses. Some deaths have been at- 
tributed to the use of headache patent medicines. 

Eye Strain. 

So much has been Avritten about eye strain and 
knowledge of its consequences is now so general, that 
little need be .said on this subject here. The common 
symptoms of eye strain in adults are — headache, dis- 
inclination to continued reading, nervousness, indi- 
gestion and blurred vision. Sometimes the only or 
chief symptom present is nervousness. Many cases of 
nervous breakdown among teachers have been due to 
this cause alone. The writer knows a prominent 
teacher who for three years suffered from extreme 
neurasthenia and was finally obliged to spend several 
months in a Sanatorium, only to discover at last that 
the entire trouble was caused by muscular uribalance 
which produced constant eye strain, or what is more 
exactly the fact, nerve strain. 

Many most unexpected results have been produced 
by this defect. The teacher who feels special interest 
in this subject is referred to the "Biographic Clinics" 
of Dr. Gould, in which it is shown very conclusively 
that undetected and therefore uncorrected eye strain 
has been the chief cause of the misery suffered by such 



146 The Health Index of Children 

noted men as Charles Darwin, Thomas Henry Huxley, 
Carlyle, Wagner, and many others. 

The ability to read ordinary print at the usual dis- 
tance does not prove that e^'e defects may not be pres- 
ent, for some such defects are at least in part overcome 
by an unconscious nervous effort on the part of the 
individual. Slight degrees of astigmatism often pro- 
duce worse results than more serious forms of eye 
trouble, because the individual overcomes the defect 
through constant but unrecognized nerve strain. If 
the defect were more noticeable to the individual it 
would probably be recognized earlier and corrected by 
the aid of glasses. The most common uncorrected and 
often unnoticed eye defects are astigmatism, muscular 
unbalance and far sight, (hyperopia). 

Colds. 

Every teacher must have noticed how easy it is to 
take cold when very tired or exhausted. Anything 
Avliich reduces the resisting powers of the body makes 
one more susceptible to disease of any kind. 

It is because the bacteria of colds are nearly always 
l»resent and because most people do many unwise 
things which weaken their natural powers of defense 
against them that colds are so connuon. Those who 
learn how to live normal lives hardly ever suffer from 
colds. On the other hand, many people eat too much, 
overdress themselves, live in badly ventilated places, 
or do other unhygienic things — and then wonder why 
they are constantly subject to colds. 

There are many other reasons to account for a 
tendency to colds. For example diseased tonsils and 



The Health of the Teacher 147 

obstructions in the nose, such as turbinates and certain 
other groAvths, render an individual an easy victim. 

Other indirect causes which make one liable to take 
cold are usually one or more of the following: poor 
nutrition, exhaustion, constipation, exposure to dust, 
indigestion, bad ventilation, improper methods of 
clothing the body, which usually result in keeping the 
skin surface damp, and improper care of the feet. 

Once knowing the causes of the disease we call a 
cold, the prevention is fairly easy. Any one who is 
not in delicate health can learn to avoid colds. No 
one can afford not to do so. 

Cool daily bathing increases the resistance of the 
body. Such baths train the blood vessels of the skin 
to dilate and contract quickly. This is desirable in 
order that we may promptly meet sudden changes 
in temperature by increasing or checking perspira- 
tion. The practice of cool bathing is beneficial be- 
cause it trains the nervous system which directly con- 
trols the capillaries. 

The use of heavy underclothing which keeps the sur- 
face of the body constantly moist is to be avoided. 
Linen and cotton mesh are better than wool; the ma- 
terial must be such as to allow evaporation of per- 
spiration. The habit of bundling up the neck with 
furs or other wraps is a bad practice, except when one 
is exposed to very cold weather. Eubbers and over- 
shoes should never be kept on long at a time, and 
heavy stockings need never be worn. 

Bedrooms must be well ventilated with open win- 
dows, and the bedclothes should be warm but light in 



148 Tub Hkaltii Index of Ciiilduen 

weight. The practice of sleeping out of doors is de- 
sirable when the climate aud siirroundings permit. 
Teachers particularly should be careful that the air 
of the school room is not too dry, as is apt to be the 
case in steam-heated schools. Air that is too dry takes 
up moisture from the nose and throat and is almost 
sure to result in catarrh. Sudden chilling should 
be avoided as far as possible. Sensible care of the di- 
gestive apparatus and attention to the bowels are most 
essential. 

When one does come down with a cold despite pre- 
caution, it should never be neglected. The best method 
of cure is to go to bed for a day or two in a well- 
ventilated room, take plenty of hot drinks, eat little 
food, and use some simple cathartic. Washing out 
the nose and throat with weak hot salt water and soda 
is frequently of great benefit. 

The results of frequent or neglected colds are often 
serious. Many teachers are constantly having colds, 
and one result of this is chronic catarrh. Much mucus 
is secreted from the nose and throat, and often the 
bronchial tubes become involved. This means that 
intiammation is always present and that certain 
harmful bacteria never cease their labors. Teachers 
who suffer in this way are likely to have a decided 
tendency toward tuberculosis. Sometimes these ca- 
tarrhal conditions travel back through the eustachian 
tube connecting the throat with the ear, and serious 
trouble in the ear follows. Most cases of deafness 
are due to neglected catarrh. 

The usual "catarrh remedies" are either worthless 



The Health of the Teacher 149 

or only temporary in the relief they give. Catarrh 
always needs careful attention from a skillful physi- 
cian. No one can be constantly subjected to colds and 
not suffer seriously, for though a single cold may seem 
trivial, repeated attacks predispose to catarrh, tuber- 
culosis, and probably to pneumonia. 

The various physical disorders of teachers must of 
necessity react upon their pupils in at least two ways ; 
first, through general unfavorable influence; second, 
through the direct transmission of disease. A teacher 
with tuberculosis may easily infect numbers of her 
pupils, and tuberculosis is not infrequent among teach- 
ers, especially in California and the South, where cli- 
mate attracts the invalid. Even a cold may bring ser- 
ious sickness to one or several of the pupils of the 
teacher affected. Colds, as Mr. iVllen says, "can always 
be charged to some one else. . .the chief danger of a 
cold is to our neighbor." When our neighbors are chil- 
dren, the danger is doubly great, for mere colds may 
lead by indirect methods to pneumonia, tuberculosis, 
or even diphtheria. One teacher with a cold may easily 
infect a whole class, and in some of the pupils the re- 
sult is pretty sure to be serious. Sometimes "colds" 
affecting either teachers or pupils will be regarded as 
much a cause for exclusion from school as the more 
serious diseases such as scarlet fever, measles, and 
whooping cough now are. 

The splendid effect upon pupils of exuberant health 
in the teacher can never be over-estimated, but the 
deadly depressing effect on the young of ill-health is 
rarely appreciated. The delicate or sick teacher is 



150 The Health Index of Children 

nearly always fatigued. ''Fatigue begins at the top 
and works down." The nervous teacher is fatigued all 
of the time. Often that is why she is nervous. The 
dyspejitic teacher is fatigued, for dyspepsia, mal-nutri- 
tion, and fatigue are inseparable companions. Fatigue, 
as ordinarily expressed in lowered vital activity, means 
fatigue poisons in the blood. Disease, over-work, vit- 
iated air, social dissipations, anger, and other undue 
emotional uncontrol all result in fatigue poisons which 
sooner or later reach the nerve cells of the brain inhibit- 
ing clear thinking and muscular activity. Fatigue re- 
duces the powers of self-control. The fatigued teacher 
is a fussi/ one, frequently she is an angry one also. 
Cunnilative fatigue, as Dr. Gulick well says, reduces 
the whole personality, mental, moral, physical to low- 
er and cruder levels. ^ Fatigue leads to crooked think- 
ing and "crooked thinking by a teacher leads to crooked 
thinking by a pupil." Fatigue accompanies all dis 
eased conditions in time and the degree of it is directly 
proportional to the degree of physical disarrangement 
in the system. 

Frequently the ill-health of teachers is a direct result 
of the maladjustments of the school systeuL "Teachers 
no less than pupils, have a heaven-ordained right to 
work so adjusted that the highest possible physical con- 
dition shall be maintained automatically.'' Teachers, 
as well as pupils, have the right to a healthful environ- 
ment, and reasonable teaching requirements are as 
mm'h due them as are reasonable lessons due her pup- 
ils. 

i"Mind and Work", (Gulick). 



The Health of the Teacher 151 

Trustwortli}^ certificates of physical fitness ought to 
be required of teachers at the opening of every school 
year. In my own experience as Medical Director of 
Schools I have time and again observed teachers afflict- 
ed with tuberculosis, asthma, deafness, defective vision, 
neurasthenia, deformities, malnutrition, anaemia, heart 
disease, and a number of other disorders. The schools 
which have introduced medical supervision of pupils, 
only have done but half their duty. Teachers must not 
only be physically sound Avhen thej'^ begin the year, but 
they must themselves habitually obey the common laws 
of health. Disobedience of these common laws by the 
teacher means ineffective teaching of them. 

From every teacher with abundant vitality and force- 
ful personality, there radiates an influence for good 
which far transcends mere mental capacity, however 
great that may be. 



PART III. 

HEALTH ORGANIZATION IN SCHOOLS 



CHAPTER XII. 



AN OFFICE SYSTEM FOR CITY SCHOOL HEALTH DE- 
PARTMENTS. 

There are certain fundamentals underlying modern 
office systems, these being simplicity, brevity, and ac- 
cnrac3\ Some form of card index most fully satis- 
fies these requirements. Even if the system adopted 
is small enough to be housed in a few desk drawers, it 
is well from the beginning to establish a number of 
divisions of the department.- The following cover 
practically every field of activity in the modern school 
health department. 

Department of Hygiene. 

1. Division of Sanitation. 

2. Division of Health Education. 

3. Division of Medical Examination. 

4. Division of School Nursing. 

5. Division of Relief. 

6. Division of Epidemiology. 

7. Division of Statistics. 

The designation '^'Department of Hygiene" is used 
to avoid confusion with a probable '^Department of 
Health," existing as part of the city government. 

Correspondence. In general any communication 
from the office of the Medical Director of schools, 

^Prepared for this book by Dr. John N. Force. 



154 The Health Index of ('hha)Uen 

.slioiild be typewritten on standard sized paper bear- 
ing an official letter head. It should be numbered 
and a carbon co^n' retained and filed. Clippings 
should be filed in envelopes under a subject in- 
dex, and magazine or book references may be recorded 
on the outside of these subject envelopes, 

l)irislu)i of ^anitatioiL All matters pertaining to 
the sanitation of the school buildings belong to 
this division. In order to acquaint himself with 
existing conditions, the Medical Director should 
make, or cause to be made, a careful sanitary- survey 
of each building. This record is kept in his office, and 
alterations made as conditions improve. There are 
many forms for this survey of school buildings. Al- 
len's "Civics and Health" gives one, and there are sev- 
eral in (Jerhard's ''Guide to Sanitary Inspections." 
Insanitary conditions should be innnediately reported 
to the sui)erintendent of schools by letters describing 
Ihem, and suggesting remedies. 

Division of Health Education. If the Medical Di- 
rector conducts lectures for parents, he should 
have announcements of the course printed for dis- 
tribution. If he Avishes to give information in se- 
lected cases he may prepare a series of health leaflets. 
Suggestions for these can be found in the circulars 
issued by many state and local boards of health. As 
examples of these may be mentioned the cards used 
in the schools of Everett, Massachusetts for cases of 
skin disease. These cards combine information with 
a i)resciMption which ma}^ be torn oft' and taken to a 
pharmacist. The same principles will apply to the 



Office System 155 

training of teachers in reading the health index, main- 
taining sanitary room conditions, and teaching hy- 
giene. "Suggestions to Teachers and School Physi- 
cians Kegarding Medical Inspection" is the title of a 
pamphlet issued by the Massachusetts Board of Educa- 
tion, which contains many excellent ideas. ''Health 
Studies" D. C. Heath & Co., is an example of a gram- 
mar grade text in hygiene on absolutely modern lines. 
Kecord of lectures delivered, and printed matter dis- 
tributed should be kept in the office of the Medical 
Director. 

Division of Medical Examination. From this divis- 
ion originally developed all the others and it is still 
the most important. 

Man}^ forms have been advocated for this work, from 
separate cards for each physical examination to a 
complete health record extending over the whole school 
life. After study of these the one herewith submitted 
has been developed. This card includes in the health 
record of each pupil a complete "follow-up" system. 
The other side of the card maj- be used for the 
attendance and scholarship record for the whole 
period of school life. A practical point in print- 
ing cards on both sides is to pattern after the im- 
pressions on coins. The back of a card may then be 
read without removing it from the filing drawer. This 
form may be filed in duplicate. One copy in the cus- 
tody of the Principals follows the changing fortunes 
of the child from grade to grade. The other is filed 
alphabetically in the office of the Medical Director to 
await the next annual examination of the child. At 



15G The Health Iadex of Children 

the time of exaniinatiou, some form of notice islioiild 
be sent to the parents of each defective child. One 
system advocates a different card for each of the com- 
mon physical defects. This is an absolnte Avaste of 
printing and a needless increase in red tape. The 
second notice is sent Avlien the teacher reports lack 
of attention to the first within a stated time. If both 
notices are disregarded, the division of school nursing 
is called into action. 

Once a mouth the Trincipal notes on his individual 
record cards, defects which have been corrected since 
the last monthly report. He then reports these 
corrections and the uncorrected remainder to the 
Medical Director. The latter from this report may 
then bring his card records up to date. V>y use of a 
"code" for indicating defects and their corrections the 
whole work is mucli simi)litied. 

lUrisioii of ScJiool Xiirsiiif/. The School Nurse 
is the medium of comunniication between the Medi- 
cal Director and the family. The work of school 
nurses has been well described in a recent article on 
the school nursing system of (iermany. "They are 
to visit the homes of the parents of such school chil- 
dren as receive no medical treatment in spite of the re- 
peated messages, and to endeavor to induce the par- 
ents to follow the advice of the school physician. If 
a child in the school is noticeable for its uncleanliness, 
or insufficient clothing or poor nutrition, the nurse is 
to inform herself regarding the economic status of 
the parents, and the housing and nutritive condition 
of the child.'' 



Office System 157 

In many places the school nurse treats the com- 
mon skin diseases, and does minor surgical dress- 
ings. The advisability of this in a city Avith proper 
dispensary facilities is questionable. The nurse needs 
as much training in social service, as in nursing. 
She should make a weekly report of visits and a social 
survey of each family visited, and maintain a card file 
of these surveys at the office of the Medical Director, 
noting changes as they occur. 

Division of Relief. Allen in "Civics and Health" 
commends our American way of "getting things 
done" in contrast to the foreign way of "doing 
things." It is better, he maintains, not to care for 
our indigent defectives in the schools, but to refer 
them for medical, dental, or social attention to exist- 
ing relief agencies. Record should be kept of such 
references, and the agency should be asked to report 
back to the Medical Director a memorandum of the 
relief afforded. 

Division of Epidemiology. The conduct of this 
division is determined to some extent by the man- 
ner in which contagious diseases of school children 
are supervised by the local Board of Health. If the 
report of a case is received from the health depart- 
ment, at the office of the Superintendent of schools 
by telephone, the operator should make out duplicate 
exclusion cards, one for the information of the Princi- 
pal of the school, and the other for the Medical Direc- 
tor. By having these forms bound up alternately 
paper and card, carbon sheets may be used. The 
paper to the Principal includes a detachable notice 



158 The Health Index of Children 

to the parents of the child excluded, aud the dupli- 
cate record on the card can in the same manner be 
divided to send as a notice to the health department, 
and retain a stub for the file of the Medical Director. 
The notice to the health department serves as a check 
on the telephone message, or as an original notice if 
the case Avas discovered at school. Note should be 
made when the child is readmitted. From his card 
record the Medical Director can make up his ''pin 
map." A pin map is a powerful public health object 
lesson if displayed on the walls of the Medical Direc- 
tor's office. A map of the city is ruled oif into school 
districts, and for every case of contagious disease a 
jjin is placed in the square where the child resides. 
If the common black-headed pins are dipped in differ- 
ent colored sealing wax, the distribution of each di- 
sease can be determined and many useful facts de- 
duced therefrom. 

Division of Statistics. If the preceding card files 
and reports have been carefully kept, the labor of the 
monthly statistical report of the Medical Director to 
the Superintendent of schools, will be minimized. 

Summary of Forms. 

1. Letter head. 

2. Sanitary Survey of School Building. 

3. Educational Pamphlets. 

(a) Announcement of lectures for parents. 

(b) Announcement of lectures for teachers. 

(c) Health leaflets. 

(d) Pamphlets on school hygiene. 



Office System 159 

4. Individual Health Record Card. 

5. First Notice to Parents. 

6. Second Notice to Parents. 

7. Teacher's or Principal's Monthly Card Report 
of Defectives. 

8. Social Survey Card. 

9. Nurse's Weekly Card Report of visits. 

10. Card Request for Relief. 

11. Exclusion Card. 

12. District Map of City. 

13. Medical Director's Monthly Card Report, 
(made in duplicate.) 

In this system all forms requiring to be filled out 
and filed, with the exception of the sanitarj^ survey 
of school building, are on cards five by eight inches. 
They can therefore be housed in uniform filing draw- 
ers. The retained stub of the exclusion notice can 
be filed in a drawer which has been partitioned length- 
wise. Four forms only require duplication, and only 
eight require writing, four by the Medical Director, one 
bj' the Medical Director and Principal, one by the Prin- 
cipal alone, and two by the nurse. There is one an- 
nual form, two forms used monthly, and one Aveekly. 
The others are filled out as occasion arises. Foes of 
red tape who see too much detail in this system, will 
notice that Providence, Rhode Island uses twenty- 
five forms in her medical inspection of schools. 



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CHAPTER XIII. 



A GENERAL PLAN FOR HEALTH SUPERVISION IN 
SCHOOLS. 

The necessity for careful supervision of the health 
and development of school children is no longer open 
to argument. In the best towns and cities of the 
United States the people themselves are demanding 
such supervision as one of the most vital functions 
of the public school system. No school can any longer 
claim a place in modern educational progress which 
ignores or neglects the health conditions of its pupils. 
A child to be properly educated must have good health. 

Organization Plan. 

Medical inspection, or as it is better called, health 
supervision of schools, is provided for by methods 
which will vary all the way from desultory volun- 
tary services to the complete, well jjaid, methodical 
plan of New York City. In general it may be safely 
stated that schools get just about what they pay for. 
One does not usually expect satisfactory service from 
a voluntary or poorl}^ paid superintendent or teacher. 
Whatever sort of public service is worth having is 
usually worth paying for. Health officers in schools 
should, therefore, be regarded as any other employees 
of the school system. We frequently hear of a school 
medical officer inspecting several thousand children 



JG6 The Health Index of Children 

in a year, or even less time, while giving to this work 
onl}^ a portion (and usually a small one) of his time, 
and receiving for such work a pittance of |200 or less. 
Now such a piece of work as this is sometimes worth 
just about what is paid for it, but more often its value 
is much less. No inspector can possibly cover several 
thousand cases yearly in a few hours per week, and 
do valuable work for the schools. Buch a nuin is just 
what his name implies, an ''inspector." He inspects^ 
it is quite true, but he never studies nor adjusts. 

To be truly useful, health work in our schools re- 
quires training, aptitude, time, and reasonable recom- 
pense. Except in cities where the health department 
is organized on a large and complete plan with its var- 
ious departments in charge of well-qualified directors, 
the medical supervision of schools ought to be under 
the direct control of the Board of Education. This is 
true because medical work in schools naturally forms 
an essential part of our general educational system. 
It is a great mistake to think of such work as first of 
all medical, for it is first of all educational. It must 
aid the boy and girl in healthy growth and develop- 
ment; it must help the school to adapt its work to 
individual physical and mental conditions; it must 
assist in the correction of existing physical defects 
and in the prevention of others; it must teach the 
fundamental elements of preventive medicine; it 
should superintend in a general way the teaching of 
physiology and hygiene. 

Parents Not Always Wise in Health Matters. 
If all parents were sufficiently wise in health mat- 



General Plan for Health Supervision 167 

ters, it would probably be quite unnecessary for 
schools to make any special study of the physical con- 
dition of the children entrusted to their care. All 
that could then be fairly required would be the guar- 
antee of a healthful school environment, including 
such things as good ventilation, correct methods of 
lighting and heating, sanitary plumbing, the elimina- 
tion of contagious diseases, frequent recesses, sufficient 
attention to physical education, and the proper kind 
of health instruction. But it is a fact and not a 
theory that not all, or even most parents, are wise in 
matters pertaining to the health conditions of their 
children. It becomes, therefore, the plain duty of the 
school department to furnish not only a healthful 
school environment, but also a careful guardianship 
of the personal health of its pupils. 

If medical supervision were synonymous with medi- 
cal inspection, from which our present health work in 
schools originated, it would be very easy for one phy- 
sician to inspect ten or more thousand children per 
year but with careful medical supervision the number 
examined will usually be far less. Medical inspection 
as it was ordinarily carried out merely contemplated 
the superficial examination of pupils for the detection 
of skin diseases and signs of the ordinary contagious 
diseases of childhood. 

Medical supervision includes far more than inspec- 
tion. It means the health study in a broad sense, 
of the children in the schools, with an attempt to ad- 
just them to their physical environment. It means a 
study of the conditions of sight and hearing, an ex- 



1()8 The Health Index of C'hh.drex 

amiuation for evidences of nasal ob.strnction, diseased 
tonsils, seriously defective teeth, disorders of nuti-ition 
and development, nnbalauced nervous organizations, 
for signs of early heart or lung disease, for enlarged 
glands, skin diseases, as well as syni])toms of children's 




A Group of Childrcu Awaiting' Physical Kxamiiiatiou. 

common contagious diseases. The careful physical 
study of school children has, therefore, supplanted the 
early and inadequate method of inspection, and has 
shown clearly that there is an intimate relation between 
the child's physical condition and his mental progress 
and future success. 



General Plan for Health Supervision 169 

A Practical Working Plan For a City. 

In order to discover those pupils who most need 
physical attention, a plan can be devised whereby the 
teacher makes the first selection and refers the pupils 
selected to the examining physician. A convenient 
method is to furnish a card about 8x10 inches, having 
printed on one side of it, twenty-five arbitrary signs 
and symptoms of physical defects. lUiese are ex- 
pressed in terms which any teacher can understand 
and use. For example terms such as the following 
may be used: (See page 154). 

Posture, nutrition, endurance, mental activity, ap- 
pearance of teeth, mouth-breather, frequent absences, 
inattention, delinquency in studies, squinting or other 
signs of eye trouble, deafness, nasal voice, colds^ 
offensive breath, signs of contagious diseases, condi- 
tion of skin, cleanliness of person, vicious habits, home 
conditions, nervous symptoms. 

Reading the Health Index. 

Any intelligent teacher can observe points such as 
these among her pupils if she tries. This is what is 
called reading the "Health Index." A set of cards 
is given to each teacher by the principal. The 
teacher fills in the parent's name, pupils name, age 
grade, and home address, at the top of the card, and 
then simply makes a check opposite the sign or symp- 
tom she has observed, as for instance, "nasal voice." 
She may perhaps fill out ten or twelve of these cards 
in a room of twenty-five or thirty pupils. These cards 
are then handed to the principal, who in turn gives 



170 The Health Index op Children 

them to the school physician when he calls. The phy- 
sician then calls these pupils to the principal's oflBce 
one at a time. Here they are carefully examined and 
the results are recorded on the reverse side of the 
pupil's cards. This examination includes the eyes, 
ears, nose, throat, heart, lungs, skin, teeth, general 
physical appearance, and indications of any contagious 
or nervous disease. 

The teacher receives the cards belonging to her room 
after the examinations have been made of her pupils, 
follows the cases as far as possible and makes a 
monthly report to the physician. If this is not done 
the school physician soon loses all knowledge of the 
cases he has examined. When teachers are aware of 
the physical embarrassments of their pupils, they are 
then in a position to treat them more intelligently in 
their daily school work. AMienever the examining 
physician discovers physical conditions which need 
attention, a notice is sent to the parent of the child 
suggesting further examination and advice from the 
family physician, dentist or specialist, as the case 
may require, and offering the opportunity for further 
advice at his office. 

The Work of the School Nurse. 

The school nurse should accompany the school phy- 
sician on his visits to schools. When home visits are 
advisable for purposes of personal advice, explana- 
tion, or for other reasons, the nurse can note this fact 
during the physical examination and call at the home 
as early as possible afterward. These personal calls 
are productive of much good and are nearly always 
received with manifestations of interest and with con- 



General Plan for Health Supervision 171 

sideration. Sometimes the nurse can show parents 
how to construct a cheap sleeping porch for a child 
much in need of fresh air. This has accomplished 
much good in many of our Berkeley homes already. 
Sometimes the nurse can give suggestions about proper 
food for a child and demonstrate how it ought to be 
cooked. Sometimes the nurse can provide means for 
attention to medical or dental conditions which would 
otherwise be neglected. Among the very needy, the 
nurse can personally dress any minor accident cases, 
take care of some contagious diseases and care for 
simple eye inflammations. 

The nurse often discovers conditions of home en- 
vironment which explain many of the defects found 
by the physician in his examinations in the school. 
The relation of home health to school health is in many 
ways an intimate one, and the school nurse is indis- 
pensable in studying this relation and in providing 
means for the proper adjustment of many of the un- 
favorable situations she is able to detect in her per- 
sonal visits. 

Of the one hundred and fifteen different house visits 
made by the Berkeley school nurse during the fall term 
of 1909, practically ninety per cent of them were pro- 
ductive of good results. 

Of the first seven hvmdred and fifty children referred 
to the school physician by the teachers in Berkeley, 
nearly seventy per cent were found to be in need of 
m'edical or dental attention. Of these the greatest 
number showed defects of nutrition, enlarged lymph 
glands, and badly decayed teeth. 



172 The Health Index of Children 

Following the Cases Needing Attention. 

Without an adequate system for following cases 
which have been found to need medical or dental at- 
tention, very little good can be accomplished by any 
method of health supervision. The following plan 
will be found to work satisfactorily, but no doubt other 
ideas would serve the purpose equally well. After 
a pupil has received his physical examination and the 
case has been recorded, send his card back with him 
to his teacher. P^ach teacher will thus have in her 
possession the record cards for those of her pupils 
who have received an examination. From time to 
time she must attempt to discover what attention the 
notice to the parent has received and record this on 
the pupil's card. Where no attention has been given 
to the case, the physician can be notified and a second 
notice sent home together \vith an invitation to bring 
the child to the office for further examination and 
advice. In many cases it will be found necessary to pro- 
vide medical or dental service for these cases in order 
to get anything done for the child. If possible some 
sort of a medical and dental school dispensary should 
be established. If this cannot be accomplished, then 
arrangements can usually be made with individual 
physicians and dentists to care for such children at 
their private offices. Pure charity service ought 
usually to be avoided, but arrangements for very small 
charges must be made. An advisory health committee 
composed of several physicians and dentists will be 
found to be of very great service in any school health 
department. It is very desirable in some schools to 



General Plan for Health Supervision 173 

have the pupils' school standing, attendance, etc., on 
one side of the card and the physical record on the 
other. By this method it is often possible to explain 
retardation, slow mentalitj^, nervous manifestations, 
etc., hj the physical conditions found present. The 
school nurse should keep a careful card record of all 
her home visits and from time to time should inform 
the examining physician of the results she has ob- 
tained. For this purpose a special card must be used. 
The question often arises as to whether a doctor 
ought to give all of his time to school health super- 
vision in cities of some size. Arguments of value can 
be made on both sides of this question. The discussion 
usually adjusts itself however, as few places are 
at present willing to pay salaries which justify effi- 
cient physicians in giving up all their time to this 
kind of medical specialty. It is the writer's opinion 
that men or women who devote only half of their time 
to health work in schools will usuall}^ give the best 
service. By this method better physicians can be in- 
duced to undertake the work than where all of their 
time is demanded. It is also true that physicians who 
are in touch with a variety of medical cases will gener- 
ally prove more valuable to the schools than those who 
confine themselves to strictly school medical work. 
Health work in schools is of necessity very monotonous 
and extremely limited in medical scope, therefor© 
the best service cannot be expected from physicians 
who are not in touch with a large variety of cases out- 
side of those found in schools. In time the medical 
officer who gives his time exclusively to health work 



174 The Health Index of Children 

will almost inevitably fall into unfortunate ruts 
through the very nature of his routine occupation. 

It is sometimes possible to employ a school health 
officer who is also teaching Hygiene or a related sub- 
ject in a University or other institution of learning, or 
who is a city or county health official. In these in- 
stances the combination works quite satisfactorily even 
though the individual may not be engaged in actual 
private practice. 

A competent physician in the schools should be 
well paid. The office can never be one of dignity if he 
is not. In general it may be said that such an official 
should receive the same salary for one half of his time 
as is given to the best paid principal in the same city 
for his full time. On this basis the best of medical 
talent can be obtained, but on any other salary basis 
efficient service will rarely be secured. This plan is 
self adjusting, small places paying small salaries and 
larger ones proportionately larger salaries. The real 
danger of a school health position degenerating into a 
political job must never be forgotten. 

A Plan for Small Communities. 

In small towns and in the country it will often be 
found quite impossible to organize a school health 
department on anything except the simplest basis. 
Sometimes it Avill be found quite hopeless to employ 
either an examining physician or a school nurse. In 
such instances the teacher herself must learn how 
to read the Health Index of her pupils and advise 
the parents what children ought to be taken to the 



General Plan for Health Supervision 175 

family pliysician, dentist, or specialist for a thorough 
examination. Many times it will be possible for the 
Principal of the school to make it his particular duty 
to read the Health Index of all the pupils in his school. 
In small communities it is sometimes feasible to em- 
ploy a physician to spend a very limited amount of 
time in the schools where he may co-operate with the 
Principal or the teachers in making physical examina- 
tions and aid them with expert advice. It will usually- 
be found best for teachers to confine their work to gen- 
eral inspection, calling in the physician to confirm 
their observations by more careful examinations. 

Voluntary medical service is frequently offered, but 
it is rarely advisable to accept it for reasons that are 
self-evident. Even the smallest places can afford to 
pay for a limited amount for medical advice in schools. 
At least twice each year a physician ought to make a 
careful health survey of the sanitary conditions of all 
school grounds and buildings and this should be under- 
taken only by a doctor especially qualified for such 
work for many good physicians have never had experi- 
ence or training in school sanitation. In small coun- 
ties it may be possible to employ a physician to super- 
vise the health of all schools in the county. 

If select cities such as Pasadena, where four hun- 
dred and twenty-one of the first seven hundred and six 
pupils examined were found to be in need of medical 
or dental attention, and about sixty per cent of the first 
seven hundred and fifty examined in Berkeley were 
found in the same condition, it would appear that there 
can be no argument against the necessity for medical 
supervision in less favored places. 



170 The Health Index of CHn^DREX 

GENERAL HEALTH SURVEY TO AID THE TEACHER IN 
DETECTING DEFECTIVE PUPILS, 

School Grade Teacher 

Pupil Age Address 

1. Do you drink tea? How many cups? 

2. Do you drink coffee? How many cups? 

3. Do you drink cocoa or 

chocolate? How many cups? 

4. Do you drink milk? How many glasses? 

5. Do you eat your lunch at school? 

6. Do you ever come to school 

without breakfast? How often? 

7. Do you ever go without lunch? How often? 

8. What time do you go to bed? 

9. What time do you get up? 

10. Do you do any work out of school hours? 

11. Do you study any out of school 

hours? Plow much? 

12. Do you have headache very often? 

13. Does the print blur w^hen you read? 

14. Can you read writing on the board easily? 

15. Can you always hear the teacher easily? 

16. Do you ever have ear ache? 

17. Do you ever have ruiiiiiiig; ear? 

18. Do you ever have tooth ache? 

19. Have you ever been to a dentist? 

20. Do you own a tooth brush? 

21. Do you use a tooth brush every day? 

22. Do you have your bedroom window kept open or closed 

at night? 

23. Are the windows in your house screened in summer? 

24. What school work do you like best? 

25. What school work do you like least? 



HEALTH SURVEY OF PUPILS WHO HAVE BEEN EXAM- 
INED BY THE SCHOOL PHYSICI.\N. 

1. Names of pupils who have received a Physical examination 

and whose card shows one or more defects. 

2. Character of defects. 

3. Has any attention been given to case? 

4. Will attention be given soon? 

5. Special suggestions about any case. 
ILLUSTRATION: 

John .Jones, Washington School, 5th grade. 
Adenoids; no attention. 
Teeth; attention. 

Eyes; will receive attention. 

Nurse ought to visit home which is at 2526 University Ave. 

HARRIET SMITH, 

Teacher. 



CHAPTER XIV. 



SOME DETAILS OF THE PHYSICIAN'S EXAMINATION. 

In examining the throat, wooden tongue-depressors, 
which may be used once only and then discarded, are 
absolutely necessary. In testing eyes, no special light 
apparatus is necessary. All that is required is the 
Snellen Test Type Card and good daylight. In test- 
ing the hearing a stop-watch is desirable because the 
answers of children are often very deceptive. Each 
eye and each ear must be tested separately. It is well 
to test the color sense while testing the eyes, and for 
this purpose colored discs or yarns may be employed. 
Experience is required in testing the eyes of children 
because they often transpose, misread, or omit letters. 
Many children find some difficulty in reading the 20|20 
line, and for practical purposes I believe that the abil- 
ity to read the 20|30 (oculists' opinions to the contrary 
notwithstanding) should be considered satisfactory 
unless other signs of eye trouble are present. 

The ordinary star shaped astigmatism test-card is 
valuable in routine eye tests. Special care should be 
directed to the squint or "cross eye." Very few people 
understand that the squint or cross eye nearly always 
becomes T)lind unless it receives early care. It is im- 
portant for parents to know that cross eye can very 
often be corrected by the early use of proper glasses. 



178 The Health Index of Chh.dren 

The ''near point" of reading nnist be observed. In 
children over ten years of age it is about four inclies. 
Inability to read at this distance suggests hyperopia. 

The importance of seeing that parents take their 
children to oculists and not to opticians can not be 
over-stated. Many parents of school children patron- 
ize the "doctor" in the rear of a jewelry store unless 
they are carefuly instructed to the contrary. 

The importance of observing crooked and prominent 
teeth must not be overlooked. This condition as is 
well known to careful examiners, is usually due to 
adenoids. Adenoids can indeed usually be diagnosed 
by the facial expression, the appearance of the teeth, 
and the Jti(jJi arch of the hard palate. An examina- 
tion with the finger is rarely advisable or necessary. 
The relation between deafness, earache, discharging 
ear, and enlarged tonsils on the one hand, and adenoids 
on the other must always be kept in mind. 

Rather large tonsils are common in young children 
even when no diseased condition is present, and, as is 
well known, this condition tends to disappear of itself. 
Unless the enlargement is excessive I do not believe 
that such tonsils always indicate the necessity for 
medical or surgical treatment. It is often a part of 
a general lymphatic enlargement. 

An ordinary nasal speculum used without special 
artificial means of illumination is all that is necessary 
in routine work on the nose. Even the speculum may 
usually be dispensed with. Polypi are very easily di- 
agnosed from symptoms of obsti*uction and nose bleed. 
Enlarged turbinates in school children are in my ex- 
perience rare. 



Some Details op the Physician's Examination 179 

The examination of the heart is very important. 
With a Bowles Stethoscope or a phonendoscope, the 
necessity for the removal of the clothing is avoided. 
A skilful examiner can always detect murmurs in this 
way. When they are discovered a more complete ex- 
amination with the chest bared can be made to deter- 
mine the presence or absence of hypertrophy or dilita- 
tion. Murmurs on the left side in the second inter- 
space are so commonly found as to be negligible. They 
are practically always accidental or functional. A cer- 
tain amount of enlargement of the heart during the 
rapidly growing age, especially near the age of pu- 
berty, we all know to be common and of no great con- 
sequence. In this condition, however, boys and girls 
ought to be cautioned about athletic strains or excess- 
ive exercise of any sort. 

Functionally w^eak hearts among children are often 
encountered, and appropriate advice ought to be given 
in these cases. Such hearts are found more espec- 
ially among girls of the high school age. Students of 
this age also need careful examinations for incipient 
tuberculosis. Unless there are special indications for 
it, a careful examination of the lungs is rarely necess- 
ary in grammar grade pupils. Such examinations are 
indeed quite impossible unless the clothing be removed, 
which is not often advisable. An important matter 
of technique, however, is a rough test of the ability to 
expand the lungs and chest. It is truly astonishing 
how few pupils know how to breathe properly. This 
they must be taught. 

More important perhaps than all else is a careful ex- 



180 The Health Index of Children 

amination of the teeth. The neglect of the first teeth 
is practically imiversal, and even the second teeth need 
attention in probably sixty per cent of the children 
of most schools. 

As a matter of routine, an examination of the lymph 
glands of the neck is important. Enlarged glands 
are often associated with bad teeth, tubercular condi- 
tions, and general malnutrition. It is my observa- 
tion that really healthy children rarely show even mod- 
erate enlargement of these glands. 

Kough tests of muscular control, co-ordination, etc., 
may always be made quickly and easily. Incipient 
chorea (St. Vitus Dance) will often be noticed in 
this way. Sex examinations, however desirable they 
may be, are not to be recommended at present except 
with the consent and presence of the parent, and at 
his request. 

Lastly the general posture, state of nutrition, color, 
and cleanliness, of these little folks must be taken in 
at a glance by the examiner. 

After completing the cards from a given room, the 
physician visits the room himself and observes the pu- 
pils at work. He will probably detect some cases 
which the teacher has overlooked. He will also ob- 
serve the conditions of temperature, light and the gen- 
eral sanitary surroundings of the pupils. By this plan 
of office examination and personal inspection, the phy- 
sician gradually covers every room in the building. 
It is needless to say that tact and understanding of 
children are most essential in this work. 



CHAPTER XV 



THE CO-OPERATION OF SCHOOL HEALTH DEPART- 
MENTS WITH OTHER HEALTH AGENCIES.l 

Medical supervision of schools is rapidly becoming 
an increasingly important factor in modern education. 
The necessity for such careful supervision of the health 
and development of school children is no longer an 
open question. 

Only the most unprogressive communities now op- 
pose this sort of work, and only careless communites 
fail to avail themselves of its advantages. No school 
can today claim an important place in modern educa- 
tional progress which ignores or neglects the health 
conditions of its pupils. Like most other new devel- 
opments, school health supervision methods have 
evolved from very small, unorganized beginnings. As 
in most other projects, one community learns very 
little from others, but each attempts to work out its 
own problems, thereby falling into the same errors, 
confronting the same difficulties, and wasting about 
the same amount of energy. We have today no stan- 
dardization of methods^ and endless useless discussion 
results from this fact. In the light of the experience 
of many progressive cities such standardization in 
essential matters might now be rather easily estab- 

^A paper read by the Author at the St. Louis meeting of the 
American Academy of Medicine, 1910. 



182 The Health Index of Chh.drex 

lislied, thus saving an enormous amount of time and 
energy to towns and cities whieli wisli to inaugurate 
this work. 

Most communities have in existence one or several 
sorts of health organizations but few of them have at- 
tempted to correlate the work of the various health 
agencies. A concrete example of what may be accom- 
plished by such useful correlation is furnished by the 
city of Berkeley, California, and for this reason this 
is presented as typical of what may be done in many 
other places. 

Berkeley is a city of about forty thousand people. 
It is a suburb of San Francisco and is the seat of the 
University of California. Health supervision was only 
organized here recently and the usual difficulties 
have had to be met. A reasonably expert Board of 
Health was of course in existence and it employs a 
Health Officer who devotes part of his time to the city 
work, receiving for this service the moderate compen- 
sation of about a thousand dollars a year. 

Since the great San Francisco fire of 190G a small 
medical clinic or dispensary has been in operation 
under the direction of three physicians. For several 
years the Berkeley Charity Organization has also been 
in operation, under a Board of Directors which em- 
ploys a Secretary and visiting nurse. The medical 
dispensary was situated on the west side of the 
city near the manufacturing district and conse- 
quently among the homes of the foreign element. 
The Charity Organization was situated near the busi- 
ness center. 



Co-operation 183 

The Medical Director of Schools was elected by the 
Board of Education at a reasonable salary to devote 
the entire school day (from 9 a. m. to 3 p. m.) to the 
health work of the schools, and was given a suite of 
offices in connection with the rooms of the Board of 
Education. An arrangement was made whereby the 
Charity Organization Nurse should devote one half of 
her time to that agency and one half to the city schools. 

It soon became clear that the four health agencies 
in Berkeley, viz. the City Board of Health, the Berke- 
ley Charitj^ Organization, the West Berkeley Clinic, 
and the School Health Department were wasting con- 
siderable time, energy and money. To correct this 
condition the following plan was carried into effect. 

1st. The rather inadequate Clinic was, after much 
discussion, and Avith some difficult}^, re-organized into 
a dispensary with a staff made up of fifteen represent- 
ative physicians, instead of the former small and 
somewhat exclusive staff of only three. 

2d. The Charity Organization was induced to Join 
hands with the new Berkeley Dispensary. To this 
end a large dwelling house near to both the school 
and city health departments was rented, and these two 
rival health organizations established under one roof, 
thus saving much money in rent, much time and 
energy, and resulting in common rather than separate 
efforts toward raising means for support. 

3d. The Alameda County Dental Society now or- 
ganized two Dental Dispensaries, one for Oakland and 
another for Berkeley. By means of a theatre party 
and through private contributions of the dentists them- 



184 The Health Index of Children 

selves sufficient means were secured to completely 
equip in the most modern fashion these tv\'o dental 
dispensaries. The Board of Education at once offered 
co-operation with the Berkeley Dental Dispensary by 
placing at its disposal offices in connection with those 
of the Medical Director of Schools. 

4th. The City Health Department has closely as- 
sociated itself with all of the above health agencies 
and is co-operating in every possible manner. 

The result of the combination thus described is that 
all of the health agencies, including: The School 
Health Departnifent, The City Health Department, 
The Charity Organization, The Medical Dispensary 
and The Dental Dispensary are now located within 
one block of one another and are combined under three 
roofs instead of five. 

A city Charity Commission has recently been ap- 
pointed by the Mayor and is closely associated with 
the agencies just named. The local Chapter of the 
Red Cross has united its etforts Avith the others. 
Within a few months Berkeley therefore has succeed- 
ed in uniting toward one common end the efforts of 
the following health agencies : 

1. The School Health Department. 

± The City Health Department. 

3. The Charity Organization. 

4. The Medical Dispensary. 

5. The Dental Dispensary. 

6. The City Charity Commission. 

7. The Red (^ross. 

What has been done on a small scale in Berkeley, 



Co-operation 185 

the State Board of Health and State Medical Societj- 
have done on a much larger one. The ^'California 
Public Health League" has been formed, and this 
will as far as possible unite the efforts of every 
organized health agency in the State, including "The 
Society for the Prevention of Syphilis and Gonorrhoea." 
The School Health Department in Berkeley feels 
that its efficiency has been increased many fold 
through the co-operation just described. It has de- 
vised a system of records which is simple, yet complete. 
Every school case cared for by a.nj one of the health 
agencies is reported by card to the office of the Medi- 
cal Director of Schools. The school nurse keeps an 
accurate card record of every school home visited. No 
case is entitled to medical or dental treatment which 
is not first recommended by the Charity Organization. 
An advisory Health Committee of fifteen physicians 
has been appointed by the Board of Education to aid 
the school physician in his work. A lecture Staff of 
six physicians, dentists and nurses has been organ- 
ized to give lectures on various health topics at three 
different centers for the benefit of parents and school 
children. A woman physician has been added to the 
Health Department of Schools who teaches Hygiene 
in the High School and has general supervision of the 
health of the High School girls. What has been rather 
easily accomplished in Berkeley by the School Health 
Department and other health agencies in less than 
a year can be done in almost any other city with 
tjie expenditure of a little time, thought and energy. 



18() The Health Index op Children 

BIBLIOGRAPHY. 

This list is not intended to be even approximately complete, 
but it does furnish a working basis for those interested in 
Child Hygiene and School Sanitation. 

For a more extended list of books, magazines and pam- 
phlets, on various phases of Hygiene, Public Health, etc., the 
reader is referred to the Bibliography in the author's Health 
Studies, D. C. Heath & Co. 

Child Hygiene in General. 

*Physical Nature of the Child (Rowe) Macmillan Co. 

*The Development of the Child (Oppenheim) Macmillan Co. 

*The Study of Children (Warner) Macmillan Co. 

*Civics and Health (Allen) Ginn & Co. 

* Youth (Hall) D. Appleton & Co. 

Bibliography of School Hygiene (Burnham) (contains 436 
titles) found in the Proceedings of the N. E. A., 1898. 

The Nervous System of the Child (Warner) Nev^^ York, 1900. 

♦Fatigue (Mosso) New York, 1900. 

The Psychological Clinic — Philadelphia. 

Journal of the Royal Sanitary Institute — London — 90 Buck- 
ingham Palace Road. 

Journal of Educational Psychology — 2427 Yorke Street, Bal- 
timore. 

Medical Inspection — Massachusetts Board of Education. 

The Doctor in the Schools (Dr. Hackworth Stuart) — H. K. 
Lewis, 136 Gower St., W. C. London, (1908). 

Various Publications of the Bureau of Municipal Research — 
New York City. 

Various Publications of the Russell Sage Foundation Fund 
— (Dept. of Child Hygiene). 

The World's Work. 

McClure's. 

Good Housekeeping. 

Journal of the American Academy of Medicine — Easton, Pa. 



Bibliography 187 

Bulletin of the California State Board of Health (Especially 
February, 1910.)- 

Bulletin of the Michigan State Board of Health. 

Bulletin of the Massachusetts State Board of Health. 

Bulletin of the North Carolina State Board of Health (Es- 
pecially for September, 1910), (Teacher's Edition). 

*The Survey — New York. 

Medical Inspection of Schools. 

*Medical Inspection of Schools — (Gulick and Ayres) Char- 
ities Publishing Co., New York, (1908). 

Medical Inspection of Schools — (Hogarth) Oxford Medical 
Publications, London, (1909). 

Medical Inspection of School Children — (Mackenzie) Wm. 
Hodge & Co., Edinburgh. 

Guide Practique du Medecin-Inspecteur Des Ecoles — (Dr. L. 
Dufestel) O. Doin & Son, Paris, (1910). 

School Hygiene. 

Hygiene Scholaire — (Dr. L. Dufestel) O. Doin & Son, Paris, 
(1909). 

*School Hygiene — (Dr. Ludwig Katelman) C. W. Bardeen, 
Syracuse, N. Y., (1899). 

School Hygiene— School Hygiene Publishing Co., 2 Char- 
lotte St., London, W. 

School Hygiene — (Shaw) Macmillan Co. 

*School Hygiene — (Porter) Longmans Green & Co., New 
Yorki (1906), (An excellent practical book). 

*International Archiv fur Schulhygiene — (Otto Gmelin), 
Munich. (This is one of the most important publications in 
School Hygiene to-day. Extracts of articles are printed in 
French, German and English). 

Handbuch der Schulhygiene — '(Dr. Leo Burgenstein and Dr. 
Aug. Netolitzky) Gustav Fischer. 



ISS TUK HlOALTII IXDKX OF ("HILDIJEX 

Medical Text Books and General Reading. 

Commoner Diseases of the Eye — (Wood and Woodruff) 
iiJnglehard & Co., Chicago, (1909). 

Diseases of the Eye — (May). 

Manual of Otology — (Bacon) Lea Bros. & Co., Philadelphia. 

Diseases of infancy and childhood — (Holt) D. Appleton & Co. 

Tuberculosis — (Bridge) W. B. Saunders & Co. 

Instinct and Health — (Hutchinson) Dodd, Mead & Co., 
New York. 

Mind and Work — (Gulick) Doubleday, Page & Co., New 
York. 

*The Efficient Life— (Gulick) Doubleday, Page & Co., New 
York. 

Outdoor Schools — (Ayres) Doubleday, Page & Co., New 
York. 

Hygiene of the Mind — (Clouston) Dutton & Co., New York. 

Health Studies— (Hoag) D. C. Heath & Co., Boston. 

*National Vitality — Document 419, (Irving Fisher) Govern- 
ment Printing Office, Washington. (Contains exhaustive ref- 
erences to subjects in Hygiene, Public Health, and all related 
topics. Should be in the hands of every teacher). 

Magazines, Pamphlets, Reprints, Etc. 

*Health Pamphlets for Schools — (for teachers and parents). 
(Dr. E. B. Hoag) Whitaker & Ray-Wiggin Co., San Francisco. 

1. The Nose, Throat and Ear. 

2. The Eye. 

*The How and Why of the Teeth — Alameda County Dental 
Society, Oakland, Cal. 

The Care of the Teeth— (Dr. R. C. Ohmsted) Board of 
Education, Pasadena, Cal. 

Tuberculosis in Children— (Dr. Langley Porter) San Fran- 
cisco, Cal. 

*Titles marked with an a.sterisk are particularly recom- 
mended to teachers. 



DEC 30 1910 



One copy del. to Cat. Div. 



BK SG mo 



